Ethiopia Bednet Utilization Study: Why Some Nets Owned Are Not Used

This 25-page report describes a study carried out to determine levels of ownership and use of insecticide-treated nets (ITNs) in households in the Oromia and Amhara Regions of Ethiopia. Although nightly use is optimal, sometimes people use their nets sporadically or do not use them at all. To understand why, and to develop effective communication for optimal net use and public health impact, this research was carried out by NetMark, a project at the Academy for Educational Development (AED) funded by the United States Agency for International Development (USAID).

The study used both quantitative and qualitative methods. The survey instrument included close-ended pre-coded questions as well as 4 open-ended questions. The study also included observation of nets in homes, in addition to market visits in the towns of Nazreth, Bahar Dar, and Jimma to assess commercial availability of nets, current prices, and leakage. The data were collected during October 2007, at the end of the rainy season when mosquito density and malaria transmission is high.

Overall net ownership was very high, with 91% of households owning at least one net, and most owning more than one. Overall, 75% of households owned a free net and 23% owned a purchased net, but there was considerable variation by region and urban-rural location. Since most nets owned were free nets, the vast majority of nets owned (84%) were the long-lasting ITNs (LLINs) PermaNet® distributed in the prior 2 years by the government and non-governmental organisations (NGOs).

Respondents from the 9% of households that did not own any nets were asked why. There was no single dominating reason. Some said they did not need nets, as malaria was not a problem for their family or community. Some said they were not aware of the free distribution, or were not able to collect nets during the distribution period. In areas where free nets were not distributed, some families said they were waiting for a free net to be given them, and others said they could not afford one.

Traders in all 3 urban markets visited (Bahar Dar, Nazreth, Jimma) said that there are people who go to communities following free distribution, pay the family a small amount for the net (typically 5-10 birr, or about US$.50 - US$1.00 dollar), and sell nets by the hundreds or thousands to market-sellers or other vendors. In an effort to avoid free nets being sold, some communities had opened the package before giving it to families. However, these opened packages were also found in the market.

Amongst those owning nets, during malaria season (October) in 2007, 65% of nets owned reportedly had someone sleeping under them the prior night. Nets that were paid for were more likely to be used than free nets (76% vs 63%). Among all households in the sample, the percent of household members who had slept under a net the prior night was 47%; the percent of children under 5 who had slept under a net the prior night was 60%; and the percent of pregnant women under a net was 57%. Among net-owning households, the comparable figures were 51% of all household members, 64% of children under five, and 66% of pregnant women. In one-third (33%) of net-owning households, respondents reported that all family members had slept under a net the prior night.

Often there is only one bed in the home; if so, the parents use it and the children sleep on the floor, usually on mats. Even if the household was given 2-3 nets, often only one net is used because of lack of space for hanging additional nets, or because the parents wanted to save the other nets. Nets are used for protection against mosquitoes, but people highly value the fact that treated nets kill bedbugs. Treated nets are also valued for their ability to kill fleas and flies.

After obtaining information on nets owned and usage patterns, interviewers explored reasons for inconsistent or non-use of nets. These responses - with programme and communication implications outlined after each barrier - include:

• Perception that malaria is not a problem - "Data (such as that from Mapping Malaria Risk in Africa, or MARA) on the risk of malaria in specific areas could be used to guide net distribution and accompanying community information....If risk is low but still present, that needs to be communicated. If a particular area is epidemic-prone, and nets are to be in place should another epidemic arise, that should be explained. However, net use needs to become the norm, so that people do not depend on external cues such as mosquitoes to use the net."
• Perception - and possibly reality - that ITNs have lost their effectiveness - "Access to re-treatment is needed, particularly in areas that did not receive LLINs. Community-organized dipping or distribution of individual re-treatment kits should...be available....Messages can tell people that even if their nets have small holes or tears, the nets will still be effective against mosquitoes if re-treated. Simple, specific information about how long the treatment lasts for the type of net must be communicated as part of distribution activities. Current treatment products could possibly be made more consumer-friendly....It would be useful to assess the field bioefficacy of LLINs in Ethiopia at six months, twelve months, and two years..."
• Difficulty hanging nets in Ethiopian dwellings - "Programs should seek ongoing feedback from beneficiaries of ITN programs to understand their preferences for size, shape, color and type of textile. Ease of use, especially hanging, is another important factor to consider....Programs should consider distributing conical nets or giving people a choice of nets....Where rectangular nets are distributed, extra rope or wire will need to be provided...Possibly a small community committee could help people put up the nets properly....Given the very large numbers of nets ordered from manufacturers, it should be possible to ask for design modifications to make nets more suitable for Ethiopian houses and sleeping places..."
• Nets in poor condition - "Families should be informed that some nets with holes or tears can be made effective again if treated, as long as the holes are not bigger than a fist or tears are not too large....Technical experts need to provide clear guidelines on washing frequency, and those guidelines need to be communicated to the public in a simple way..."
• Misinformation and lack of information - "It is imperative that a standard set of straightforward priority messages be developed to be delivered along with the nets...[N]ow that all free nets are LLINs, standard information can be given during distribution. Messages regarding treatment, specifically how long the treatment lasts, are key, along with a statement about maximum washing frequency. Accurate information about potential danger of ITNs should be conveyed in a way that does not cause alarm and rejection of ITNs for vulnerable groups. Community members also need to know how to hang the net properly....In addition to verbal communication during distribution, tested flyers or posters with key messages should be available as back-up reference. It is also important to communicate that as many family members as possible should sleep under a net and that the net should be used year-round. Along with factual information, families need motivation to go to the trouble of using nets, especially in areas where there are few mosquitoes. Our objective is to get people to use nets for malaria protection, but communication strategies should use messages that resonate and are likely to change behavior by drawing on other benefits people like, such as being able to sleep peacefully, nets killing other insects besides mosquitoes, or families saving money by having to buy fewer medicines or make fewer trips to the health center. It is also essential that information be received from a variety of channels..."
• Saving nets for the future - "If Ethiopia plans to rely on free nets for the foreseeable future, it needs to secure firm long-term commitments from donors and keep up yearly distribution to assure people that they will receive nets for years to come....If future distributions will not be universal but targeted toward vulnerable populations, it will be beneficial to plan now for alternative outlets for those who do not receive free nets....[S]trengthening the commercial sector is a means of ensuring a minimum sustainable supply of nets into the future."
• Nets being used for other purposes - "Nets are sometimes converted to ceiling covers, bed sheets or bed covers, curtains, tablecloths, or other household items. It appears that if one person in a community starts using nets for purposes other than as a bednet, others take up the idea....These situations show the importance of ensuring that adequate information is given along with the nets - about their purpose and how to use them....Possibly one or two households in a community can serve as models for net hanging and as information depots for the community."

The report concludes that there are a variety of barriers to be overcome: some are structural, some involve programme changes, and others require strategic communication. Well-conceived and organised communication integrated into distribution programmes and supported by ongoing public communication will go a long way toward increasing bednet use. On a yearly basis, rapid qualitative field research will keep programmes in touch with beneficiaries in order to assess how new strategies are working, identify any new barriers that have arisen, and enable modification of strategies to raise rates of net utilisation.