LLIN Evaluation in Uganda Project (LLINEUP2)—Factors associated with coverage and use of long‑lasting insecticidal nets following the 2020–21 national mass distribution campaign: a cross-sectional survey of 12 districts

Abstract

Background In 2020–2021, long-lasting insecticidal nets (LLINs) were distributed nationwide in Uganda during the COVID-19 pandemic. A cross-sectional survey was conducted in 12 districts to evaluate the impact of the campaign 1–5 months after LLIN distribution. Methods During April–May 2021, households were randomly selected from target areas (1–7 villages) surrounding 12 government-run health facilities established as Malaria Reference Centres; at least 50 households were enrolled per cluster. Outcomes included household ownership of LLINs distributed through the universal coverage campaign (UCC) (at least one UCC LLIN), adequate coverage of UCC LLINs (at least one UCC LLIN per 2 residents), and use of LLINs (resident slept under a LLIN the previous night). Multivariate logistic regression models were used to identify household- and individual-level factors associated with outcomes, controlling for clustering around health facilities. Results In total, 634 households, with 3342 residents and 1631 bed-nets, were included. Most households (93.4%) owned at least 1 UCC LLIN, but only 56.8% were adequately covered by UCC LLINs. In an adjusted analysis, the factor most strongly associated with adequate coverage by UCC LLINs was fewer household residents (1–4 vs 7–14; adjusted odds ratio [aOR] 12.96, 95% CI 4.76–35.26, p < 0.001; 5–6 vs 7–14 residents; aOR 2.99, 95% CI 1.21–7.42, p = 0.018). Of the 3166 residents of households that owned at least one UCC LLIN, only 1684 (53.2%) lived in adequately covered households; 89.9% of these used an LLIN the previous night, compared to 1034 (69.8%) of 1482 residents living in inadequately covered households. In an adjusted analysis, restricted to residents of inadequately covered households, LLIN use was higher in children under-five than those aged 5–15 years (aOR 3.04, 95% CI 2.08–4.46, p < 0.001), and higher in household heads than distantly-related residents (aOR 3.94, 95% CI 2.38–6.51, p < 0.001). Conclusions Uganda’s 2021–21 campaign was successful, despite the COVID-19 pandemic. In future campaigns, strategies should be adopted to ensure high LLIN coverage, particularly for larger households. A better understanding of the drivers of LLIN use within households is needed to guide future interventions, educational messages, and behaviour change communication strategies; school-aged children and distantly-related residents appear vulnerable and could be targeted.

Mass distribution campaign of long-lasting insecticidal nets (LLINs) during the COVID-19 pandemic in Uganda: lessons learned

“…The campaign’s coverage is consistent with a study conducted in 14 districts three months after the 2020/2021 campaign, which found that nearly all (96%) surveyed households owned at least one LLIN [ 24 ]. Another study conducted 1–5 months after distribution in 12 districts found that more than 93% of households had at least one LLIN obtained through the 2020/2021 campaign [ 17 ]. A similar household coverage of 93.35% was obtained in Benin’s 2020 mass LLIN campaign [ 25 ].…”

“…On the other hand, the 2020/2021 achieved a higher household coverage than the 2013/2014 (90%) and 2017/2018 (72%) campaigns [ 26 , 27 ]. The high household coverage in 2020/2021 could be attributed to two factors: first, the door-to-door distribution strategy [ 17 , 28 ], and second, the high availability of household members at home due to COVID-related lockdowns [ 17 ]. Mass campaigns are, therefore, effective in increasing net coverage in the population [ 29 ].…”

“…A team of two (Village Health Team) VHTs, two (Data Entry Clerks) DECs, two Local Guards, and the (Local Council) LC I chair conducted household registration and LLIN distribution electronically using the EDMS app. Registration of households and distribution of LLINs were done using the door-to-door strategy [ 17 ].…”

“…The recently concluded mass ITN distribution occurred from July 2020 to March 2021. It was implemented during the COVID-19 pandemic and was characterized with electronic data for the first time to manage beneficiary data collection and household delivery of ITNs [ 17 ]. COVID-19-related disruptions necessitated modification of the initial campaign design to avoid postponement of LLINs distribution.…”

Predicting malaria risk considering vector control interventions under climate change scenarios

“…In this country, malaria control relies primarily on indoor residual spraying of insecticide (IRS) programs targeting epidemic areas and nationwide campaigns of long-lasting insecticides nets (LLINs). Uganda was the first country to introduce mass distribution of LLINs and had one of the highest coverage rates with 93% of households reportedly owning at least one LLIN in 2021 21 . Despite sustained efforts in vector control since the 2000s, malaria remains a leading cause of morbidity and mortality in Uganda, accounting for 30–50% of outpatient visits, 15–20% of all hospital admissions, and up to 20% of all hospital deaths 22 .…”