Malaria Protection Equity in a Conflict-Affected County: LLINs Utilization Among Vulnerable Subgroups in Fashoda County, Upper Nile State, South Sudan — A Cross-Sectional Analytical Study

Background: Malaria disproportionately burdens vulnerable subgroups—pregnant women, children under five, internally displaced persons (IDPs), and semi-nomadic communities—in conflict-affected South Sudan. Fashoda County, Upper Nile State, hosts a mosaic of such populations with distinct risk profiles and utilization barriers. Evidence on how LLINs utilization varies across these subgroups is essential for achieving equity in malaria protection. Objective: To characterize LLINs utilization patterns and identify subgroup-specific determinants among distinct vulnerable population segments in Fashoda County, South Sudan, using a Health Equity Lens and vulnerability-stratified analytical approach. Methods: A cross-sectional analytical study among 334 households was conducted using PPS cluster sampling across four settlement types. A composite vulnerability index was constructed from displacement status, income level, and geographic access indicators. Sex-disaggregated analysis, distribution channel effectiveness assessment, and SDG alignment mapping were applied alongside Spearman correlation and ordinal logistic regression in IBM SPSS v25. Results: A composite vulnerability ladder identified semi-nomadic cattle camp households (score 88/100), pregnant women (82/100), and children under five households (78/100) as the highest-risk subgroups, yet with the greatest predicted benefit from targeted interventions. ANC-integrated continuous distribution demonstrated the highest utilization efficiency (74%) and equity score (82) among delivery channels—substantially outperforming mass campaign alone (50.3% utilization efficiency). Predicted probability modelling showed that combined knowledge-plus-access improvements could raise utilization to 78.2% for the general population and 7