Unveiling Urban Malaria Dynamics: Beyond Insecticide Treated bed nets Coverage to Heterogeneous Human Behaviors and Spatial Realities

Abstract Background: Despite cost efficiency, insecticide-treated bed nets (ITNs) are still not extensively used: less than 2% of children sleep in completely functioning ITNs, and less than 40% of owners in Accra, Ghana, utilize them effectively. Thus, the predicted reduction in the prevalence of malaria throughout the country and in Accra is still far from being attained. This study deconstructs urban malaria dynamics, revealing the complex interplay of ITNs, spatial heterogeneity, and human behaviors. Methods: As such, we assessed urban malaria prevention knowledge, developed a metapopulation framework aligned with empirical findings, and incorporated behavior scenarios to better understand urban malaria dynamics. Results: Having an ITN does not guarantee its effective use, especially in densely populated areas. Limited living space and repurposing are identified as key barriers in Accra, Ghana, with healthcare visits emerging as catalysts for ITN use. Mathematical models that incorporate spatial and demographic factors emphasize the importance of achieving 60% ITN use in each community patch for epidemic elimination. A proxy-based approach to modeling human behavior overcomes the challenge of revealing that ITN coverage alone does not guarantee malaria expected reduction in prevalence. Conclusion: Shorter ITN distribution intervals and targeted education to improve community health are among the recommendations.