What drives the consistent use of long-lasting insecticidal nets over time? A multi-method qualitative study in mid-western Uganda

Abstract

BackgroundThe distribution of long-lasting insecticidal nets (LLINs) through universal coverage campaigns is a widely adopted approach for the prevention of malaria at scale. While post-distribution surveys play a valuable role in determining cross-sectional levels of LLIN retention and use, as well as frequently cited reasons for non-use, few studies have explored the consistency of LLIN use over time, within the expected lifespan of the net, and the factors which may drive this.MethodsIn this qualitative study, 74 in-depth interviews were conducted with (male) household heads and (female) caregivers of children in LLIN recipient households, as well as community health workers, in Buliisa, Hoima and Kiboga districts in Uganda, 25–29 months following a LLIN mass campaign distribution. A triangulation approach to data analysis was taken, incorporating thematic analysis, most significant change and positive deviance.ResultsThe factors found to be most influential in encouraging long-term LLIN use were positive experience of net use prior to the distribution, and appreciation or awareness of a range of benefits arising from their use, including protection from malaria as well as importantly, other health, lifestyle, social and economic benefits. Social support from within the community was also identified as an important factor in determining continued use of LLINs. Net use appeared to be more consistent amongst settled urban and rural communities, compared with fishing, pastoralist, refugee and immigrant communities.ConclusionsA multitude of interplaying factors encouraged consistent LLIN use in this setting. Whilst the protection of malaria remains a powerful motivator, social and behaviour change (SBC) strategies should also capitalize on the non-malaria benefits of net use that provide a long-term rationale for consistent use. Where supplies are available, SBC campaigns should promote replacement options, emphasizing ongoing net care and replacement as a household responsibility, thus reducing dependence on free distributions. The triangulation approach to qualitative data analysis enabled increased confidence in the validity of findings and an enhanced contextual understanding of the factors promoting consistent net use in mid-western Uganda. The approach should be considered when designing future studies to explore factors driving net retention and use trends.Electronic supplementary materialThe online version of this article (doi:10.1186/s12936-016-1101-4) contains supplementary material, which is available to authorized users.

A qualitative study of use of long-lasting insecticidal nets (LLINs) for intended and unintended purposes in Adami Tullu, East Shewa Zone, Ethiopia

“…The qualitative findings highlight the locals’ apparent fascination with not just the direct, intended malarial protection benefit, but the collateral benefits including the repelling and killing of all sorts of insects such as bed bugs, fleas, flies, spiders, and other crawlers. Similar findings from a Uganda-based study also show the relevance of this, where Strachan et al [ 14 ] report on the wider benefits of using nets, as experienced by targeted communities, beyond the prevention of malaria. They argued while the protection of malaria remains a powerful motivator, the non-malaria benefits of net use were also found very important in driving consistent use.…”

Free versus purchased mosquito net ownership and use in Budondo sub-county, Uganda

“…For example, a study in Gambia showed that privacy obtained by sleeping under a net to be a motivating factor [ 32 ], and in Zanzibar, aspects of comfort appeared to play a key role in personal decisions [ 33 ]. The importance of emphasizing the non-health advantages to sleeping under nets have also been suggested in response to seasonal fluctuations in mosquito numbers which can affect the perceived threat of malaria and, by association, net use [ 8 ]. This evidence suggests future educational campaigns could benefit from advocating non-malaria benefits of net use, in addition to malaria-prevention, to provide a long-term rationale for consistent use.…”

Social vulnerability of children aged 5 to 15 years to malaria in Madagascar: 3 anthropological studies LLIN use

“…Cultural components as factors in net use have been found in other countries [46][47][48]. In Loreto, Peru, mosquito net use is integrated into people's habits.…”

“…[55]. In two studies in Uganda and Tanzania, the habit established by "previous positive experiences" of sleeping peacefully was cited as a factor in the development of a "net culture" according to Koenker et al [48,50] and has resulted in "consistent use of LLINs despite uctuations in risk perception" [50].…”