The gap between having and using: socioeconomic inequalities in long-lasting insecticidal net coverage among children and adolescents in rural Guinea

Malaria is a major health issue in sub-Saharan Africa, including Guinea, affecting children under five and rural populations, with a prevalence of up to 30% in some areas. Although long-lasting insecticidal nets (LLINs) are effective, inequalities in access and use persist across wealth, geography, and age groups; however, detailed data are limited. This study assessed socioeconomic inequalities in LLIN access and use among children and adolescents. We analysed data from a cohort study conducted between March 2022 and February 2023 in Maferinyah, rural Guinea, with monthly visits to households of children and adolescents aged 1–19. Socioeconomic position (SEP) was derived using an asset index and categorised into terciles. LLIN access and use-given-access were analysed using mixed logistic regression models adjusted for sociodemographic and seasonal factors. Socioeconomic inequalities were quantified using concentration and Erreygers indices with cluster bootstrap confidence intervals. Pathway and decomposition analyses assessed the contribution of access to LLIN to inequalities in effective LLIN use (defined as use regardless of access). The odds of LLIN access were higher among middle-SEP (aOR = 3.84; 95% CI 1.31–11.96) and high-SEP households (aOR = 3.76; 95% CI 1.18–12.71) than among low-SEP households. Inequalities in effective LLIN use were driven by disparities in access rather than by use behaviour. Although LLIN use among those with access exceeded 80% across all socioeconomic groups, effective use in the overall study population was lower among low-SEP households (29.6%). Significant pro-rich socioeconomic inequalities were observed for both LLIN use (Erreygers index (EI) = 0.386; 95% CI 0.151–0.594) and access (EI = 0.412; 95% CI 0.168–0.636). Decomposition analysis suggested that socioeconomic inequality in effective LLIN use was almost entirely explained by differences in access (98.8% of the total variance). Malaria prevention in rural Guinea is unequal, leaving poorer children and adolescents less protected than wealthier ones. This gap stems from unequal access to LLINs rather than differences in net use among households with nets. The study showed that the poorest families did not have access to nets in the first place. Addressing this inequity requires improved distribution strategies targeting the poorest and most vulnerable households, rather than behavioural interventions for net use only.