Impact of a behaviour change intervention on long-lasting insecticidal net care and repair behaviour and net condition in Nasarawa State, Nigeria.

BACKGROUND: While some data on net durability have been accumulating in recent years, including formative qualitative research on attitudes towards net care and repair, no data are available on how the durability of a net is influenced by behaviour of net maintenance, care and repair, and whether behavioural change interventions (BCC) could substantially impact on the average useful life of the net. METHODS: The study used an intervention-control design with before-after assessment through repeated cross-sectional household surveys with two-stage cluster sampling following Nasarawa State's December 2010 mass campaign. All campaign nets were 100-denier polyester, long-lasting insecticidal nets (LLIN). Baseline, midline, and endline surveys occurred at one-year intervals, in March 2012, March 2013, and April 2014, respectively. Outcome measures were the proportion of confirmed campaign nets with observed repairs, and the proportion in serviceable condition, measured with proportionate hole index (pHI) and according to WHO guidelines. RESULTS: For all respondents, exposure to BCC messages was strongly correlated with increased positive attitude towards care and repair, and increases in attitude were positively correlated with observed net repairs, and with the proportion of nets in serviceable condition. In a multivariate regression model, positive care and repair attitude (OR 6.17 p = 0.001) and level of exposure (1 source: OR 4.00 p = 0.000; 3 sources: OR 9.34 p = 0.000) remained the most significant predictors of net condition, controlling for background and environmental factors. Nets that were tied up had 2.70 higher odds of being in serviceable condition (p = 0.001), while repairs made to nets were not sufficient to improve their pHI category. Estimated median net lifespan was approximately one full year longer for nets in households with a positive compared to a negative attitude. CONCLUSION: Exposure to multiple channels of a comprehensive BCC intervention was associated with improved attitude scores, and with improved net condition at endline. It is possible for BCC interventions to change both attitudes and behaviours, and to have an important effect on overall median net lifespan. Care and repair messages are easily incorporated into existing malaria BCC platforms, and will help contribute to improved net condition, providing, in principle, more protection from malaria.

What happens to lost nets: a multi-country analysis of reasons for LLIN attrition using 14 household surveys in four countries.

BACKGROUND: While significant focus has been given to net distribution, little is known about what is done with nets that leave a household, either to be used by others or when they are discarded. To better understand the magnitude of sharing LLIN between households and patterns of discarding LLIN, the present study pools data from 14 post-campaign surveys to draw larger conclusions about the fate of nets that leave households. METHODS: Data from 14 sub-national post-campaign surveys conducted in Ghana, Senegal, Nigeria (10 states), and Uganda between 2009 and 2012 were pooled. Survey design and data collection methods were similar across surveys. The timing of surveys ranged from 2-16 months following their respective mass LLIN distributions. RESULTS: Among the 14 surveys a total of 14,196 households reported owning 25,447 nets of any kind, of which 23,955 (94%) were LLINs. In addition, a total of 4,102 nets were reported to have left the households in the sample: 63% were discarded, and 34% were given away. Only 255 of the discarded nets were reported used for other purposes, representing less than 1% of the total sample of nets. The majority (62.5%) of nets given away were given to or taken by relatives, while 31.1% were given to non-relatives. Campaign nets were almost six times (OR 5.95, 4.25-8.32, p < 0.0001) more likely to be given away than non-campaign nets lost during the same period. Nets were primarily given away within the first few months after distribution. The overall rate of net redistribution was 5% of all nets. DISCUSSION AND CONCLUSION: Intra-household re-allocation of nets does occur, but was sensitive to current household net ownership and the time elapsed since mass distribution. These factors can be addressed programmatically to further facilitate reallocation within a given community. Secondly, the overwhelming majority of nets were used for malaria prevention. Of the repurposed nets (<1% overall), the majority were already considered too torn, indicating they had already served out their useful life for malaria prevention. National programmes and donor agencies should remain confident that overall, their investments in LLIN are being appropriately used.

Universal coverage with insecticide-treated nets - applying the revised indicators for ownership and use to the Nigeria 2010 malaria indicator survey data.

BACKGROUND: Until recently only two indicators were used to evaluate malaria prevention with insecticide-treated nets (ITN): "proportion of households with any ITN" and "proportion of the population using an ITN last night". This study explores the potential of the expanded set of indicators recommended by the Roll Back Malaria Monitoring and Evaluation Reference Group (MERG) for comprehensive analysis of universal coverage with ITN by applying them to the Nigeria 2010 Malaria Indicator Survey data. METHODS: The two additional indicators of "proportion of households with at least one ITN for every two people" and "proportion of population with access to an ITN within the household" were calculated as recommended by MERG. Based on the estimates for each of the four ITN indicators three gaps were calculated: i) households with no ITN, ii) households with any but not enough ITN, iii) population with access to ITN not using it. In addition, coverage with at least one ITN at community level was explored by applying Lot Quality Assurance Sampling (LQAS) decision rules to the cluster level of the data. All outcomes were analysed by household background characteristics and whether an ITN campaign had recently been done. RESULTS: While the proportion of households with any ITN was only 42% overall, it was 75% in areas with a recent mass campaign and in these areas 66% of communities had coverage of 80% or better. However, the campaigns left a considerable intra-household ownership gap with 66% of households with any ITN not having enough for every family member. In contrast, the analysis comparing actual against potential use showed that ITN utilization was good overall with only 19% of people with access not using the ITN, but with a significant difference between the North, where use was excellent (use gap 11%), and the South (use gap 36%) indicating the need for enhanced behaviour change communication. CONCLUSIONS: The expanded ITN indicators to assess universal coverage provide strong tools for a comprehensive system effectiveness analysis that produces clear, actionable evidence of progress as well as the need for specific additional interventions clearly differentiating between gaps in ownership and use.