Ownership–Utilization Gap in Long-Lasting Insecticidal Net Use Among Pregnant Women in Bonsu Sub-Municipality, Ghana: A Cross-Sectional Study

Abstract Background Malaria in pregnancy remains a leading cause of maternal and neonatal morbidity in sub-Saharan Africa. While long-lasting insecticidal treated nets are highly efficacious and cost-effective, consistent utilization often falls short of programmatic targets even when ownership is high. This study evaluated factors associated with the access to and utilization of these nets among pregnant women in Bonsu Sub-Municipality, Ghana. Methods A descriptive cross-sectional study was conducted among 200 purposively selected pregnant women. Structured questionnaires and direct observation of the sleeping environment were used to collect data on socio-demographic characteristics, knowledge levels, and usage practices. Results Access was near-universal, with 98.5% of respondents obtaining nets primarily through antenatal care clinics. However, a significant "Universal Access Paradox" was observed: while ownership was nearly 100%, only 43.5% of respondents had their nets correctly hung and in active use. Significant knowledge deficits were identified, with 45.7% of women incorrectly believing the insecticide was effective for only one year. Furthermore, 65.0% reported itchiness as a major adverse effect, contributing to a 35.0% non-utilization rate among owners. The structured questionnaire demonstrated good overall internal consistency (Cronbach’s α = 0.83). A supplementary cross-country comparative analysis of eight sub-Saharan African settings reporting paired ownership and utilization data showed that the present study’s ownership–utilization gap (56.0 percentage points) exceeded the cross-setting mean gap (31.3 percentage points), indicating a more pronounced paradox in this district than in comparable regional settings. Conclusions The ownership-utilization gap appears more closely associated with knowledge-efficacy deficits and physical discomfort than with supply-side barriers, although the cross-sectional design precludes causal inference. Consistent biological protection is hindered by "perceived obsolescence" of the nets and a lack of pre-emptive counseling regarding transient side effects. Limitations include the small purposive sample size and the cross-sectional design, which captures only a temporal snapshot of behavior and may be subject to social desirability bias in self-reported data. The outlook for future work necessitates a shift from passive distribution to a "Distribution Plus" model that prioritizes longitudinal behavioral tracking, male partner engagement, and the development of low-irritant insecticide coatings to ensure consistent person-nights of protected sleep.