Effect of user preferences on ITN use: a review of literature and data.

BACKGROUND: Insecticide-treated bed nets (ITNs) are the primary tool for vector control, and optimizing ITN use is a key concern of national programmes. Available evidence indicates that bed net users often have preferences for shape, colour, size, and other attributes, but it is unclear whether these preferences are strong enough to have any significant effect on bed net use, and whether countries and donors should invest in more expensive attributes in order to maximize ITN use. The link between bed net attributes, preferences, and use was investigated using a literature review and review of publicly available, nationally representative household surveys from sub-Saharan Africa. METHODS: A literature search was conducted to identify publications with data on preferences for net attributes and on associations between net attributes and use. Publicly available DHS and MIS datasets were screened for variables on net preferences and net attributes. Wald tests were run to obtain odds ratios and confidence intervals for the use of nets of various attributes in univariate analysis. A multilevel logistic regression was constructed to assess the odds of a net's use, controlling for background variables and adding random effects variables at the household and cluster level. RESULTS: Preferences for certain net attributes exist, but do not impede high rates of net use in countries where data were available. Stated preferences for shape and colour do not significantly influence net use to degrees that would require action by programme planners. By and large, people are using the nets they receive, and when they do not, it is for reasons unrelated to shape and size (primarily perceived mosquito density, heat or an excess of nets). Households in higher wealth quintiles tend to own greater numbers of conical nets, indicating that they have the ability to obtain or purchase these nets on their own, and individuals resident in higher wealth quintile households also use conical nets preferentially. CONCLUSIONS: The increased manufacturing costs for conical nets are not outweighed by the very small, often non-existent, increases in use rates in sub-Saharan Africa. Programmes that wish to explore the relationship between net attributes, preferences and use rates should include these questions in nationally representative household surveys to be able to capture trends across geographic and socio-economic groups.