Assessing bed net use and non-use after long-lasting insecticidal net distribution: a simple framework to guide programmatic strategies

Abstract

Background: Insecticide-treated nets (ITNs) are becoming increasingly available to vulnerable populations at risk for malaria. Their appropriate and consistent use is essential to preventing malaria, but ITN use often lags behind ITN ownership. In order to increase ITN use, it is necessary to devise strategies that accurately identify, differentiate, and target the reasons and types of non-use.

Methods: A simple method based on the end-user as the denominator was employed to classify each individual into one of four ITN use categories: 1) living in households not owning an ITN; 2) living in households owning, but not hanging an ITN; 3) living in households owning and hanging an ITN, but who are not sleeping under one; and 4) sleeping under an ITN. This framework was applied to survey data designed to evaluate long-lasting insecticidal nets (LLINs) distributions following integrated campaigns in five countries: Togo, Sierra Leone, Madagascar, Kenya and Niger.

Results: The percentage of children <5 years of age sleeping under an ITN ranged from 51.5% in Kenya to 81.1% in Madagascar. Among the three categories of non-use, children living in households without an ITN make up largest group (range: 9.4%-30.0%), despite the efforts of the integrated child health campaigns. The percentage of children who live in households that own but do not hang an ITN ranged from 5.1% to 16.1%. The percentage of children living in households where an ITN was suspended, but who were not sleeping under it ranged from 4.3% to 16.4%. Use by all household members in Sierra Leone (39.9%) and Madagascar (60.4%) indicate that integrated campaigns reach beyond their desired target populations.

Conclusions: The framework outlined in this paper provides a helpful tool to examine the deficiencies in ITN use. Monitoring and evaluation strategies designed to assess ITN ownership and use can easily incorporate this approach using existing data collection instruments that measure the standard indicators.

Figure 1

Flowchart representing the four categories of ITN use. ITN use categories are represented as circles. White: living in households with no ITN present; light grey: living in households owning but not hanging an ITN; dark grey: living in households that have an ITN hanging but are not sleeping under an ITN; and black: sleeping under an ITN.

Figure 2

Indicators of ITN ownership and use: survey results following integrated campaigns targeting children <5 years of age in Niger, Togo, Kenya, Madagascar, and Sierra Leone. Bars represent: white: percentage of households that own an ITN (denominator: all households); dark: percentage of ITNs hanging (denominator: all ITNs); and black: percentage of all children less than 5 years of age sleeping under an ITN (denominator: all children less than 5 years of age). Note: household ownership and ITN use by children less than 5 years of age are standard RBM outcome indicators.

Figure 3

Percentage of all children <5 years of age in each of the four ITN use categories, in Niger, Togo, Kenya, Madagascar, and Sierra Leone during the rainy season. Denominator includes all children <5 years of age. ITN use categories are: white: living in households with no ITN present; light grey: living in households owning but not hanging an ITN; dark grey: living in households that have an ITN hanging but are not sleeping under an ITN; and black: sleeping under an ITN.

Figure 4

Age specific breakdown of individuals in each of the four ITN use categories during the rainy season following an integrated campaign targeting children <5 years of age in Madagascar. Denominator includes all persons in respective age group. ITN use categories are: white: living in households with no ITN present; light grey: living in households owning but not hanging an ITN; dark grey: living in households that have an ITN hanging but are not sleeping under an ITN; and black: sleeping under an ITN. Female 16-48 includes non-pregnant women of reproductive age.

Figure 5

Age specific breakdown of individuals in each of the four ITN use categories during rainy season following an integrated campaign targeting children <5 years of age in Sierra Leone. Denominator includes all persons in respective age group. ITN use categories are: white: living in households with no ITN present; light grey: living in households owning but not hanging an ITN; dark grey: living in households that have an ITN hanging but are not sleeping under an ITN; and black: sleeping under an ITN. Female 16-48 includes non-pregnant women of reproductive age.