Outcome measured by the proportion of women with employment

Outcome variable: ITN useTheRollback Malaria indicator for ITN use, defined as percentage of women whoslept under ITN the previous night before the survey was used as the operationaldefinition for the outcome 3 Predictors Theindividual- level predictors included age of woman, parity, media exposure etc.

To examine community level factors, 3 community sociodemographics and fourcommunity health factors were selected. The predictors are described in Table1.    Table 1 Description and measurement of independent variables Community-level factors Description Community sociodemographics   % of women with employment Aggregated values of community level women employment status measured by the proportion of women with employment from individual level data categorized using tertiles as low, middle and high % of women with any education Aggregated values of community level women education status measured by the proportion of women with primary education and above from individual level data categorized using tertiles as low, middle and high % of women who are rich Aggregated values of community level women wealth index measured by the proportion of women in rich wealth index  from individual level data categorized using tertiles as low, middle and high Community health factors   % of women with autonomy on HC decisions Aggregated values of community level women’s decision status on health care measured by the proportion of women who make self-decisions on health care from individual level data categorized using tertiles as low, middle and high % of women in households with 2 or more ITNs Aggregated values of community level women households with 2 or more ITNs measured by the proportion of women in household with 2 or more ITNs from individual level data categorized using tertiles as low, middle and high % of women with perceived distance to HF a problem Aggregated values of community level women’s perceived distance to HF measured by the proportion of women  who perceived distance to HF to be a problem from individual level data categorized using tertiles as low, middle and high % of women in households with IRS coverage Aggregated values of community level women in households with IRS coverage measured by the proportion of women IRS coverage from individual level data categorized as 0 and 1 Individual-level Factors Description Age 15-24, 25-34, 35 and above Media exposure Yes/No Occupation Employed/Unemployed Education No formal education, Primary, Secondary and above Wealth Poor, Middle, Rich Parity Primigravida, Secundigravida, Multigravida Residence Rural, Urban Region Northern, Central and Southern Number of household members <5, ?5 - Average number of household members in Malawi is 4.

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5 2 Number of Under-fives None, one, two or more IRS Yes, No Health behavior Constructed with a combination of two variables, boiling water and whether they have a hand washing facility at home. Categorized as no any of the two” low”, one of the two “medium” and all of the two “high” Women autonomy on HC decisions Categorized as self, husband alone, with other Altitude >1600, ?1600 Number of ITN in household <2, ?2 Religion Catholics, Protestant, Muslims and others Distance to HF Yes/No  Ethics statementThesurvey protocol was reviewed and approved by the National Health SciencesResearch Board of Malawi, the Institutional Review Board (IRB) of ICF Macro,and the Centers for Disease Control (CDC) in Atlanta. Informed consent wasobtained at the beginning of each interview and permission was sought from theDHS program for the use of the data. Statistical analysesDescriptive analysisThedistribution of participants' characteristics (both individual andcommunity-level) according to ITN use were examined using chi-square tests.

Logistic Model Approach and measuresof associationAtwo-level multilevel logistic regression analysis was applied to measure theassociation of Individual- and community-level factors on ITN use among women(level 1) nested within their communities (level 2). The association (fixedeffects) was reported as Odds ratio and 95% CIs. In the multilevel logisticregression, four different models were fitted.

First, a null model with outcomevariable only was constructed to assess total variance between communities, andcommunity effects on the outcome. This model was included to allow thedecomposition of the variance that existed between the communities. Then modelI included individual level factors only, followed by model II with communitylevel factors only, and finally model III adjusted both individual andcommunity-level factors.

Measures of variationFurthermore,measures of variation were examined through area variance and 95% CI, Inter-clustercorrelation (ICC), median odds ratio (MOR) and Proportional Change in Variance(PVC) 4, 5.Testing model fitTotest for model fit, Akaike Information Criterion (AIC) was used. To test formulticollinearity, variance inflation factor (VIF) and tolerance were used 6.

All variableswere below 10 for VIF and more than 0.1 for tolerance hence no problem formulticollinearity. Allanalyses were done using Stata version 15.

0. Results Thestudy analyzed 16060 married women (level 1) nested within 850 communities(level 2). About 10.2% (1634) women were pregnant, 69.7% (11197) non-pregnantwith under-5 children and 20.1% (3229) non-pregnant without under-5 children(Figure 1). All the women groups were mutually exclusive.

The rate of ITN usewas 45.9%, 46.9% and 39.1% for pregnant, non-pregnant with under-5 children andnon-pregnant-women without under-5 children respectively. Distribution of participantsaccording to ITN useTable2 presents distribution of participants’ individual- and community-levelfactors according to ITN use for pregnant women, non-pregnant women withunder-5 children and non-pregnant women without under-5 children. In all studygroups, significant (p < 0.05)differences were observed between those ITN users and non-users in terms ofindividual level factors (i.e.

education, media exposure, distance to healthfacility, wealth, number of household members, number of ITN in household) andone community-level factor (i.e. percentage with two or more ITN). Nosignificant difference was observed in all groups for IRS, Altitude, region,religion, and autonomy decision on health care (i.e.

individual-level factors)and two community-level factors (i.e. percentage of women with autonomy onhealth care decisions and percentage with IRS). Inboth non pregnant women groups, the difference between ITN users and non-userswas significant (p < 0.05) interms of age, residence and health behavior.Furthermore,there was a significant (p < 0.05)difference between ITN users and non-users among pregnant women andnon-pregnant women with under-5 in terms of parity, and percentage of richwomen. No significant difference was observed for these factors in non-pregnantwomen without under-5 children.

Finally,there was a significant difference between ITN users and non-users in terms ofoccupation in non-pregnant women without under-5 children, percentage withemployment in pregnant women, percentage with any education and percentage ofwomen perceiving distance to health facility a problem in non-pregnant womenwith under-5 children.Measures of Association (Fixedeffects)Among pregnant womenTable3 showed the results of multivariable multilevel logistic regression analysesfor pregnant women. Model 3 (Final model) which controls for individual- andcommunity-level factors shows that compared to primigravida women,secundigravida and multigravida were more likely to use ITN (aOR = 1.79; 95%CI: 1.23 – 2.62 and aOR = 1.97; 95% CI: 1.

28 – 3.28 respectively). Women whoperceived distance to health facility as not a problem, with less than 5household members, from households with two or more ITNs, central region, andfrom rural areas were more likely to use ITN compared to those who perceiveddistance to health facility as a problem, had 5 or more household members, fromhouseholds with less than 2 ITNs, from northern region, and from urbanareas  (aOR = 1.44; 95% CI: 1.09 – 1.89, aOR= 2.

23; 95% CI: 1.74 – 3.11, aOR = 4.

25; 95% CI: 3.19 – 5.64, aOR = 1.66; 95%CI: 1.

2 – 2.45 and aOR = 1.63; 95% CI: 1.04 – 2.55). For community levelfactors, pregnant women in communities with a high percentage of householdswith 2 or more ITNs were more likely to use ITN compared to women incommunities with low percentage of households with 2 or ITNs (aOR = 1.47; 95%CI: 1.05 – 2.

06).Among non-pregnant women with under-5childrenTheresults of multivariable multilevel logistic regression analyses fornon-pregnant women with under-5 children are shown on Table 4. Aftercontrolling for both individual- and community-level factors, secundigravidaand multigravida were more likely to use ITN (aOR = 4.97; 95% CI: 2.62 – 9.43and aOR = 4.

55; 95% CI: 2.40 – 8.61 respectively) compared to Primigravida(model 3). Women from middle wealth households, with 2 or more under-5children, with less than 5 household members, from households with two or moreITNs, central and southern region, from rural areas and with good healthbehavior were more likely to use ITN compared to their counterparts (aOR =1.13; 95% CI: 1.

01 – 1.28, aOR = 1.12; 95% CI: 1.01 – 1.24, aOR = 1.85; 95% CI:1.65 – 2.08, aOR = 6.

89; 95% CI:6.19 – 7.65, aOR = 1.46; 95% CI:1.19 – 1.

78,aOR = 1.40; 95% CI:1.16 – 1.70 , aOR = 1.

48; 95% CI: 1.18 – 1.84 and aOR =1.19; 95% CI:1.01 – 1.39). For community level factors, non-pregnant women incommunities with middle and high percentage of households with 2 or more ITNs,and in communities with high percentage of women autonomy on health care decisionswere more likely to use ITN compared to women in communities with lowpercentage of households with 2 or ITNs and low percentage of women withautonomy on health care decisions (aOR = 1.

19; 95% CI: 1.02 – 1.38, aOR = 1.

35;95% CI:1.14 – 1.60, and aOR = 1.18; 95% CI:1.00 – 1.38 respectively).Among non-pregnant women withoutunder-5 childrenFornon-pregnant women without under-5 children, only those from households withless than 5 members, households with 2 or more ITNs, central and southern region,and rural areas were more likely to use ITN compared to their counterparts (aOR= 1.

66; 95% CI: 1.37 – 2.02, aOR = 10.72; 95% CI: 8.

59 – 13.37, aOR = 1.53; 95%CI: 1.12 – 2.09, aOR = 1.34, 95% CI:1.

00 – 1.81, and aOR = 1.57; 95% CI:1.14 –2.

16) in model 3, table 5. For community level factors, non-pregnant womenwithout under-5 children in communities with middle and high percentage ofhouseholds with 2 or more ITNs were more likely to use ITN compared to women incommunities with low percentage of households with 2 or more (aOR = 1.36; 95%CI: 1.06 – 1.75, and aOR = 1.49; 95% CI:1.15 – 1.96, respectively).

Measures of variationTable3 also shows the results of measure of variation. 11.6 %, 8.9% 6.6% and 7.

3% ofthe variation to use ITN among pregnant women was attributable to unobservedcommunity characteristics in the null model, model I, model II and model IIIrespectively. The MOR showing the effects of community heterogeneity were 1.87,1.

71, 1.58 and 1.62 for null model, model 1, 2 and 3 respectively. On the otherhand, the PCVs shows that 25.4%, 46.2%, and 39.8%, of the variance in ITN useamong pregnant women across communities were explained by individual levelfactors, community level factors and both individual-level and community-levelfactors respectively.

Innon-pregnant women with under-5 children, 13.9 %, 10.9%, 8.3% and 10.4% of thevariation to use ITN was attributable to unobserved community characteristicsin the null model, model I, model II and model III respectively. The MOR forthe communities were 2.01, 1.

83, 1.68 and 1.80 for null model, model 1, 2 and 3respectively (table 4). The PCVs showed that 24.

7%, 44.4%, and 28.9%, of thevariance in ITN use among non-pregnant women with under-5 children acrosscommunities were explained by individual level factors, community level factorsand both individual-level and community-level factors respectively.Measureof variation indicated that 17.2 %, 9.6%, 8.2% and 8.

2% of the variation to useITN was attributable to unobserved community characteristics in the null model,model I, model II and model III respectively among non-pregnant women withoutunder-5 children (table 5). The MOR were reduced from 2.20 in null model to1.76, 1.68, 1.

68 in model 1, 2 and 3 respectively (table 4). The PCVs showedthat 49.2%, 57.

1%, and 57.2%, of the variance in ITN use among non-pregnantwomen without under-5 children across communities were explained by individuallevel factors, community level factors and both individual-level andcommunity-level factors respectively.