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Meta-Analysis
. 2015 Mar 30;2015(3):CD009186.
doi: 10.1002/14651858.CD009186.pub2.

Strategies to increase the ownership and use of insecticide-treated bednets to prevent malaria

Lana Augustincic Polec  1 , Jennifer Petkovic, Vivian Welch, Erin Ueffing, Elizabeth Tanjong Ghogomu, Jordi Pardo Pardo, Mark Grabowsky, Amir Attaran, George A Wells, Peter Tugwell
Affiliations
Meta-Analysis

Strategies to increase the ownership and use of insecticide-treated bednets to prevent malaria

Lana Augustincic Polec et al. Cochrane Database Syst Rev. .

Abstract

Background: Malaria is a life-threatening parasitic disease and 40% of the world's population lives in areas affected by malaria. Insecticide-treated bednets (ITNs) effectively prevent malaria, however, barriers to their use have been identified.

Objectives: To assess the evidence on the effectiveness of available strategies that focus on delivery and appropriate use of ITNs.

Search methods: We searched the EPOC Register of Studies, CENTRAL, MEDLINE, EMBASE, HealthStar, CINAHL, PubMed, Science Citation Index, ProQuest Dissertations and Theses, African Index Medicus (AIM), World Health Organization Library and Information Networks for Knowledge (WHOLIS), LILACS, Virtual Health Library (VHL), and the World Health Organization Library Information System (WHOLIS). Initial searches were conducted in May 2011, updated in March 2012 and February 2013. Authors contacted organizations and individuals involved in ITN distribution programs or research to identify current initiatives, studies or unpublished data, and searched reference lists of relevant reviews and studies.

Selection criteria: Randomized controlled trials, non-randomized controlled trials, controlled before-after studies, and interrupted time series evaluating interventions focused on increasing ITN ownership and use were considered. The populations of interest were individuals in malaria-endemic areas.

Data collection and analysis: Two authors independently screened studies to be included. They extracted data from the selected studies and assessed the risk of bias. When consensus was not reached, any disagreements were discussed with a third author. The magnitude of effect and quality of evidence for each outcome was assessed.

Main results: Of the 3032 records identified, 10 studies were included in this review. Effect of ITN cost on ownership:Four studies including 4566 households and another study comprising 424 participants evaluated the effect of ITN price on ownership. These studies suggest that providing free ITNs probably increases ITN ownership when compared to subsidized ITNs or ITNs offered at full market price. Effect of ITN Cost on appropriate use of ITNs:Three studies including 9968 households and another study comprising 259 individuals found that there is probably little or no difference in the use of ITNs when they are provided free, compared to providing subsidized ITNs or ITNs offered at full market price. Education:Five studies, including 12,637 households, assessed educational interventions regarding ITN use and concluded that education may increase the number of adults and children using ITNs (sleeping under ITNs) compared to no education.One study, including 519 households, assessed the effects of providing an incentive (an undisclosed prize) to promote ITN ownership and use, and found that incentives probably lead to little or no difference in ownership or use of ITNs, compared to not receiving an incentive.None of the included studies reported on adverse effects.

Authors' conclusions: Five studies examined the effect of price on ITN ownership and found moderate-certainty evidence that ownership was highest among the groups who received the ITN free versus those who purchased the ITN at any cost. In economic terms, this means that demand for ITNs is elastic with regard to price. However, once the ITN is supplied, the price paid for the ITN probably has little to no effect on its use; the four studies addressing this outcome failed to confirm the hypothesis that people who purchase nets will use them more than those who receive them at no cost. Educational interventions for promoting ITN use have an additional positive effect. However, the impact of different types or intensities of education is unknown.

PubMed Disclaimer

Conflict of interest statement

AA has published papers on malaria drug quality in Africa and India. MG has been engaged in studies potentially eligible for our Cochrane Review. LAP, EU, VW, JP, ETG, JPP, GW and PT have no known conflicts of interest.

Figures

1
1
LOGIC MODEL: Strategies to increase the use of insecticide‐treated nets in households and vulnerable populations to reduce morbidity and mortality from malaria in endemic settings
2
2
Framework of components of interventions to increase the ownership and use of ITNs
3
3
Study flow diagram.
4
4
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
5
5
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 ITN Price: free vs. KES 210 to 300, Outcome 1 Ownership (purchased net).
1.2
1.2. Analysis
Comparison 1 ITN Price: free vs. KES 210 to 300, Outcome 2 Use (ITN seen hanging after 2 months, if purchased).
1.3
1.3. Analysis
Comparison 1 ITN Price: free vs. KES 210 to 300, Outcome 3 ITN used by children.
1.4
1.4. Analysis
Comparison 1 ITN Price: free vs. KES 210 to 300, Outcome 4 ITN used by adults.
2.1
2.1. Analysis
Comparison 2 ITN Price: free vs. KES 160 to 200, Outcome 1 Ownership (purchased net).
2.2
2.2. Analysis
Comparison 2 ITN Price: free vs. KES 160 to 200, Outcome 2 Use (ITN seen hanging after 2 months, if purchased).
2.3
2.3. Analysis
Comparison 2 ITN Price: free vs. KES 160 to 200, Outcome 3 ITN used by children.
2.4
2.4. Analysis
Comparison 2 ITN Price: free vs. KES 160 to 200, Outcome 4 ITN used by adults.
3.1
3.1. Analysis
Comparison 3 ITN Price: free vs. KES 100 to 150, Outcome 1 Ownership (purchased net).
3.2
3.2. Analysis
Comparison 3 ITN Price: free vs. KES 100 to 150, Outcome 2 Use (ITN seen hanging after 2 months, if purchased).
3.3
3.3. Analysis
Comparison 3 ITN Price: free vs. KES 100 to 150, Outcome 3 ITN used by children.
3.4
3.4. Analysis
Comparison 3 ITN Price: free vs. KES 100 to 150, Outcome 4 ITN used by adults.
4.1
4.1. Analysis
Comparison 4 ITN Price: free vs. KES 70 to 90, Outcome 1 Ownership (purchased net).
4.2
4.2. Analysis
Comparison 4 ITN Price: free vs. KES 70 to 90, Outcome 2 Use (ITN seen hanging after 2 months, if purchased).
4.3
4.3. Analysis
Comparison 4 ITN Price: free vs. KES 70 to 90, Outcome 3 ITN used by children.
4.4
4.4. Analysis
Comparison 4 ITN Price: free vs. KES 70 to 90, Outcome 4 ITN used by adults.
5.1
5.1. Analysis
Comparison 5 ITN Price: free vs. KES 40 to 60, Outcome 1 Ownership (purchased net).
5.2
5.2. Analysis
Comparison 5 ITN Price: free vs. KES 40 to 60, Outcome 2 Use (ITN seen hanging after 2 months, if purchased).
5.3
5.3. Analysis
Comparison 5 ITN Price: free vs. KES 40 to 60, Outcome 3 ITN used by children.
5.4
5.4. Analysis
Comparison 5 ITN Price: free vs. KES 40 to 60, Outcome 4 ITN used by adults.
6.1
6.1. Analysis
Comparison 6 ITN Price: free vs. any price (KES 40 to 300), Outcome 1 ITN ownership (purchased net).
7.1
7.1. Analysis
Comparison 7 ITN price: free vs. KES 40, Outcome 1 Ownership (measured as a share of prenatal clients who acquired program ITN).
7.2
7.2. Analysis
Comparison 7 ITN price: free vs. KES 40, Outcome 2 ITNs use (self reported at follow‐up).
7.3
7.3. Analysis
Comparison 7 ITN price: free vs. KES 40, Outcome 3 ITN use (net seen hanging at follow‐up).
8.1
8.1. Analysis
Comparison 8 ITN price: free vs. KES 20, Outcome 1 Ownership (measured as a share of prenatal clients who acquired program ITN).
8.2
8.2. Analysis
Comparison 8 ITN price: free vs. KES 20, Outcome 2 ITNs use (self reported at follow‐up).
8.3
8.3. Analysis
Comparison 8 ITN price: free vs. KES 20, Outcome 3 ITN use (net seen hanging at follow‐up).
9.1
9.1. Analysis
Comparison 9 ITN price: free vs. KES 10, Outcome 1 Ownership (measured as a share of prenatal clients who acquired program ITN).
9.2
9.2. Analysis
Comparison 9 ITN price: free vs. KES 10, Outcome 2 ITNs use (self‐reported at follow‐up).
9.3
9.3. Analysis
Comparison 9 ITN price: free vs. KES 10, Outcome 3 ITN use (net seen hanging at follow‐up).
10.1
10.1. Analysis
Comparison 10 ITN price: free vs any cost (KES 10 to 40), Outcome 1 ITN ownership.
11.1
11.1. Analysis
Comparison 11 Free ITNs, access to subsidized ITNs and social marketing vs. access to subsidized ITNs and social marketing, Outcome 1 No of households with at least one intervention ITN.
11.2
11.2. Analysis
Comparison 11 Free ITNs, access to subsidized ITNs and social marketing vs. access to subsidized ITNs and social marketing, Outcome 2 Number of households with at least one ITN.
11.3
11.3. Analysis
Comparison 11 Free ITNs, access to subsidized ITNs and social marketing vs. access to subsidized ITNs and social marketing, Outcome 3 Last night of bednet (%).
12.1
12.1. Analysis
Comparison 12 Free ITN vs. Control, Outcome 1 Nets owned per household (measured as nets owned).
12.2
12.2. Analysis
Comparison 12 Free ITN vs. Control, Outcome 2 Use (nets used per household, seen at follow‐up).
12.3
12.3. Analysis
Comparison 12 Free ITN vs. Control, Outcome 3 Usual ITN use in peak season.
12.4
12.4. Analysis
Comparison 12 Free ITN vs. Control, Outcome 4 Slept under a net the night before the survey.
12.5
12.5. Analysis
Comparison 12 Free ITN vs. Control, Outcome 5 Malaria positive (total).
12.6
12.6. Analysis
Comparison 12 Free ITN vs. Control, Outcome 6 Anaemia (Hb< 11g/dL).
13.1
13.1. Analysis
Comparison 13 Microfinancing for nets vs. Control, Outcome 1 Nets owned per household (measured as nets owned).
13.2
13.2. Analysis
Comparison 13 Microfinancing for nets vs. Control, Outcome 2 Use (nets used per household, seen at follow‐up).
13.3
13.3. Analysis
Comparison 13 Microfinancing for nets vs. Control, Outcome 3 Usual ITN use in peak season.
13.4
13.4. Analysis
Comparison 13 Microfinancing for nets vs. Control, Outcome 4 Slept under a net the night before the survey.
13.5
13.5. Analysis
Comparison 13 Microfinancing for nets vs. Control, Outcome 5 Malaria positive (total).
13.6
13.6. Analysis
Comparison 13 Microfinancing for nets vs. Control, Outcome 6 Anaemia (Hb< 11g/dL).
14.1
14.1. Analysis
Comparison 14 Free ITN vs. Microfinancing for nets, Outcome 1 Nets owned per capita (measured as nets owned).
14.2
14.2. Analysis
Comparison 14 Free ITN vs. Microfinancing for nets, Outcome 2 Use (nets used per household, seen at follow‐up).
14.3
14.3. Analysis
Comparison 14 Free ITN vs. Microfinancing for nets, Outcome 3 Usual ITN use in peak season.
14.4
14.4. Analysis
Comparison 14 Free ITN vs. Microfinancing for nets, Outcome 4 Slept under a net the night before the survey.
14.5
14.5. Analysis
Comparison 14 Free ITN vs. Microfinancing for nets, Outcome 5 Malaria positive (total).
14.6
14.6. Analysis
Comparison 14 Free ITN vs. Microfinancing for nets, Outcome 6 Malaria positive (children under 15).
14.7
14.7. Analysis
Comparison 14 Free ITN vs. Microfinancing for nets, Outcome 7 Anaemia (Hb< 11g/dL).
15.1
15.1. Analysis
Comparison 15 Malaria education vs. Diarrhea education, Outcome 1 Owns at least one ITN.
15.2
15.2. Analysis
Comparison 15 Malaria education vs. Diarrhea education, Outcome 2 Children under 5 sleeping under ITN.
16.1
16.1. Analysis
Comparison 16 Educating Heads of Households in proper ITN use, Outcome 1 ITN utilization by under‐five children at 6 months follow up.
16.2
16.2. Analysis
Comparison 16 Educating Heads of Households in proper ITN use, Outcome 2 ITN utilization by under‐five children at 12 months.
16.3
16.3. Analysis
Comparison 16 Educating Heads of Households in proper ITN use, Outcome 3 Had fever in last 2 weeks (self reported at 6 months).
16.4
16.4. Analysis
Comparison 16 Educating Heads of Households in proper ITN use, Outcome 4 Had fever in last 2 weeks (self reported at 12 months).
17.1
17.1. Analysis
Comparison 17 CHW‐provided intervention vs. control, Outcome 1 Any ITN use in house (at follow up).
17.2
17.2. Analysis
Comparison 17 CHW‐provided intervention vs. control, Outcome 2 ITN use among children <5 (at follow‐up).
18.1
18.1. Analysis
Comparison 18 Education provided to nursing mothers vs. control, Outcome 1 Prevalence of ITN use (ever use ITN).
19.1
19.1. Analysis
Comparison 19 Free ITN + undisclosed incentive for use vs. free ITN alone, Outcome 1 ITN ownership.
19.2
19.2. Analysis
Comparison 19 Free ITN + undisclosed incentive for use vs. free ITN alone, Outcome 2 ITN use (Net mounted).
20.1
20.1. Analysis
Comparison 20 Health framing vs. No framing marketing message, Outcome 1 Ownership (purchased experimental net).
20.2
20.2. Analysis
Comparison 20 Health framing vs. No framing marketing message, Outcome 2 ITN use (net seen hanging after two months, if purchased).
20.3
20.3. Analysis
Comparison 20 Health framing vs. No framing marketing message, Outcome 3 ITN used by children.
20.4
20.4. Analysis
Comparison 20 Health framing vs. No framing marketing message, Outcome 4 ITN used by heads.
21.1
21.1. Analysis
Comparison 21 Financial framing vs. No framing marketing message, Outcome 1 Ownership (purchased experimental net).
21.2
21.2. Analysis
Comparison 21 Financial framing vs. No framing marketing message, Outcome 2 ITN use (net seen hanging after two months, if purchased).
21.3
21.3. Analysis
Comparison 21 Financial framing vs. No framing marketing message, Outcome 3 ITN used by children.
21.4
21.4. Analysis
Comparison 21 Financial framing vs. No framing marketing message, Outcome 4 ITN use by heads.
22.1
22.1. Analysis
Comparison 22 Voucher given to female head vs. voucher given to both heads jointly, Outcome 1 Ownership (measured by purchased experimental net).
22.2
22.2. Analysis
Comparison 22 Voucher given to female head vs. voucher given to both heads jointly, Outcome 2 ITN use (net seen hanging after 2 months, if purchased).
22.3
22.3. Analysis
Comparison 22 Voucher given to female head vs. voucher given to both heads jointly, Outcome 3 ITN used by children.
22.4
22.4. Analysis
Comparison 22 Voucher given to female head vs. voucher given to both heads jointly, Outcome 4 ITN used by heads.
23.1
23.1. Analysis
Comparison 23 Voucher given to male head vs. voucher given to both heads jointly, Outcome 1 Ownership (purchased experimental net).
23.2
23.2. Analysis
Comparison 23 Voucher given to male head vs. voucher given to both heads jointly, Outcome 2 ITN used (net seen hanging after 2 months, if purchased).
23.3
23.3. Analysis
Comparison 23 Voucher given to male head vs. voucher given to both heads jointly, Outcome 3 ITN used by children.
23.4
23.4. Analysis
Comparison 23 Voucher given to male head vs. voucher given to both heads jointly, Outcome 4 ITN used by heads.
24.1
24.1. Analysis
Comparison 24 Verbal commitment to purchase ITN vs. no verbal commitment, Outcome 1 Ownership (purchased experimental net).
24.2
24.2. Analysis
Comparison 24 Verbal commitment to purchase ITN vs. no verbal commitment, Outcome 2 ITN used (net seen hanging after 2 months).
24.3
24.3. Analysis
Comparison 24 Verbal commitment to purchase ITN vs. no verbal commitment, Outcome 3 ITN used by children.
24.4
24.4. Analysis
Comparison 24 Verbal commitment to purchase ITN vs. no verbal commitment, Outcome 4 ITN used by heads.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Amoran 2012 {published data only}
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Cohen 2010 {published data only}
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De La Cruz 2009 {published data only}
    1. Cruz N, Crookston B, Dearden K, Gray B, Ivins N, Alder S, et al. Who sleeps under bednets in Ghana? A doer/non‐doer analysis of malaria prevention behaviours. Malaria Journal 2006 Jul;5:61. - PMC - PubMed
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Deribew 2012 {published data only}
    1. Deribew A, Alemseged F, Birhanu Z, Sena L, Tegegn A, Zeynudin A, et al. Effect of training on the use of long‐lasting insecticide‐treated bed nets on the burden of malaria among vulnerable groups, south‐west Ethiopia: baseline results of a cluster randomized trial.. Malaria Journal 2010;9:121. - PMC - PubMed
    1. Deribew A, Birhanu Z, Sena L, Dejene T, Reda AA, Sudhakar M, Alemseged F, Tessema F, Zeynudin A, Biadgilign S, Deribe K. The effect of household heads training about the use of treated bed nets on the burden of malaria and anaemia in under‐five children: a cluster randomized trial in Ethiopia. Malaria Journal 2012;11:8. - PMC - PubMed
    1. Deribew A, Birhanu Z, Sena L, Dejene T, Reda AA, Sudhakar M, Alemseged F, Tessema F, Zeynudin A, Biadgilign S, Deribe K. The effect of household heads training on long‐lasting insecticide‐treated bed nets utilization: a cluster randomized controlled trial in Ethiopia. Malaria Journal 2012;11:99. - PMC - PubMed
Dupas 2009 {published data only}
    1. Dupas P. Short‐Run Subsidies and Long‐Run Adoption of New Health Products: Evidence from a Field Experiment. The National Bureau of Economic Research 2010 Mar; Vol. Working Paper #14693. - PMC - PubMed
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Fink 2012 {published and unpublished data}
    1. Fink G, Masiye F. Assessing the impact of scaling‐up bednet coverage through agricultural loan programmes: evidence from a cluster randomised controlled trial in Katete, Zambia. Transactions of the Royal Society of Tropical Medicine and Hygiene 2012;106:660‐7. - PubMed
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Keating 2012 {published data only}
    1. Keating J, Hutchinson P, Miller JM, Bennett A, Larsen DA, Hamainza B, Changufu C, Shiliya N, Eisele TP. A quasi‐experimental evaluation of an interpersonal communication intervention to increase insecticide‐treated net use among children in Zambia. Malaria Journal 2012;11:313. - PMC - PubMed
Krezanoski 2010 {published data only}
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Muller 2008 {published data only}
    1. Allegri M, Marschall P, Flessa S, Tiendrebeogo J, Kouyate B, Jahn A, et al. Comparative cost analysis of insecticide‐treated net deliver strategies: sales supported by social marketing and free distribution through antenatal care. Health Policy and Planning 2010;25:28‐38. - PubMed
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Tarozzi 2011 {published data only}
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References to studies excluded from this review

Alaii 2003 {published and unpublished data}
    1. Alaii JA, Hawley WA, Kolczak MS, ter Kuile FO, Gimnig JE, Vulule JM, et al. Factors affecting use of permethrin‐treated bed nets during a randomized controlled trial in western Kenya. American Journal of Tropical Medicine and Hygiene 2003;68(Suppl 4):137‐41. - PubMed
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    1. Leenstra T, Phillips‐Howard PA, Kariuki SK, Hawley WA, Alaii JA, Rosen DH, et al. Permethrin‐treated bed nets in the prevention of malaria and anemia in adolescent schoolgirls in western Kenya. American Journal of Tropical Medicine and Hygiene 2003;68(4 Suppl):86‐93. - PubMed
    1. Meltzer MI, Terlouw DJ, Kolczak MS, Odhacha A, ter Kuile FO, Vulule JM, et al. The household‐level economics of using permethrin‐treated bed nets to prevent malaria in children less than five years of age. American Journal of Tropical Medicine and Hygiene 2003;68(4 Suppl):149‐60. - PubMed
Binka 1996 {published data only}
    1. Binka FN, Kubaje A, Adjuik M, Williams LA, Lengeler C, Maude GH, et al. Impact of permethrin impregnated bednets on child mortality in Kassena‐Nankana district, Ghana: a randomized controlled trial. Tropical Medicine and International Health 1996 Apr;1(2):147‐54. - PubMed
Geounuppakul 2007 {published data only}
    1. Geounuppakul M, Butraporn P, Kunstadter P, Leemingsawat S, Pacheun O. An empowerment program to enhance women's ability to prevent and control malaria in the community, Chiang Mai Province, Thailand. The Southeast Asian Journal of Tropical Medicine and Public Health 2007 May;38(3):546‐59. - PubMed
Goodson 2012 {published data only}
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Hoffmann 2009 {published data only}
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Vijayakumar 2009 {published data only}
    1. Gunasekaran K, Sahu SS, Vijayakumar KN, Jambulingam P. Acceptability, willing to purchase and use long lasting insecticide treated mosquito nets in Orissa State, India. Acta Tropica 2009 Nov;112(2):149‐55. - PubMed
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Ye 2012 {published data only}
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Yilma 2012 {published data only}
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References to studies awaiting assessment

Soleimani Ahmadi 2012 {published data only}
    1. Soleimani Ahmade M, Vatandoost H, Shaeghi M, Raeisi A, Abedi F, Eshraghian MR, et al. Effects of educational intervention on long‐lasting insecticidal nets use in malarious area, southeast Iran. Acta Medica Iranica 2012;50(4):279‐87. - PubMed

References to ongoing studies

Kilian 2012 {published data only}
    1. Kilian A. The Effect of single or repeated home visits on the hanging and use of ITN after a mass distribution campaign in Uganda. AMP Partners Meeting February 2012. [http://www.allianceformalariaprevention.com/resources‐view.php?categoryI...
Siekmans 2012 {unpublished data only}
    1. Siekmans K. Effectiveness of post‐campaign hang‐up intervention to increase ITN utilization in Togo: a cluster randomized control trial. AMP Partners Meeting February 2012. [http://www.allianceformalariaprevention.com/resources‐view.php?categoryI... - PMC - PubMed

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