Enhancing Mosquito Net Utilization
Scaling up to achieve universal coverage
Regular use of Long Lasting Insecticidal Nets (LLINs) has been shown to reduce all-cause child mortality by
around 20%. LLIN distribution in sub Saharan Africa has accelerated in the last three years, using funds provided
from the Global Fund, World Bank, US President’s Malaria Initiative, UNITAID, UNICEF, national
Governments and others. Of the 350 million LLINs needed to achieve universal coverage in Africa,
approximately 220 million nets are expected to be distributed in 2010. Endemic African countries have already
received enough nets to cover more than 60% of their at-risk populations by the end of the first quarter 2010 and
the majority of countries are now on track to achieve universal coverage by the end of 2010. Many African
countries have embarked on campaigns to rapidly increase LLIN coverage whilst also delivering LLINs through
routine health services in order to maintain those high levels of coverage.
Net utilization: Progress to date
A review of national survey data from 2006-2009 shows that the number of children under five years of age
sleeping under a LLIN remains below the target coverage of 80%. However, given the unprecedented scale up in
LLIN coverage in 2010, it is expected that utilization is actually significantly higher today compared to the map
below. It should also be noted that most household surveys take place in the dry season for logistical reasons and
given that net use is influenced by season: when it is hot and dry, and there is little malaria transmission and
mosquito biting pressure, net use tends to be lower.
In Kenya, reports indicate that ownership of at least 1
LLIN is 55.7% while the corresponding use of those
LLINs is 46.7% and 49% for children under five and
pregnant women, respectively. Thus, “use” lags
around 5-10% behind ownership. The International
Federation of Red Cross and Red Crescent Societies
(IFRC) has supported “hang-up” campaigns in
various countries where volunteers went from house
to house to promote consistent ITN use among
children and pregnant women, demonstrate proper
deployment, and at times, help the household hang
their nets. In Togo the proportion of children using an
ITN within households who received at least one
hang-up visit (80.4%) was significantly higher than
that for children within ITN-owning households who
did not have a hang-up visit (72.3%). However, in
both Niger and Madagascar, high ITN use among
children was achieved without additional
communication efforts (74.1% and 95.0%, children
sleeping under a net post campaign). There is
therefore considerable inter-country variation and in countries where coverage is high, but utilization remains sub-
optimal, individual country studies will be required to identify the reasons why, and different solutions and
communication methodologies adapted to the local context. Interpersonal, participatory, community owned
approaches tend to have the most impact, but these require specialist input and additional financing.
The two key variables with the greatest influence on net use are the number of nets in a household, and the size of
a household. LLIN use increases with the number of nets in a household, but decreases as the size of the
household increases. In order to best increase utilization of nets, endemic countries should focus on achieving
universal coverage (defined as one net for every two persons), such so that every sleeping space in a household
can be covered by an LLIN. Additionally the education and knowledge level among women has been shown to
increase net utilization in households with nets, indicating the importance of behavior change communication to
complement net distributions.
The approach of achieving universal coverage of LLINs has been adopted by all malaria endemic countries in
Africa. Once sufficient nets to reach universal coverage have been provided, other key determinants of net use
include ambient temperature, presence of nuisance biting mosquitoes, knowledge of malaria risk and knowledge
of how to hang a net.
To date, the design and implementation of locally appropriate communication strategies to accompany ITN
distribution have frequently been overlooked and/or underfunded. Communities are therefore often left without
sufficient information on the importance of ITNs, how to hang, use and maintain them properly. In addition,
documenting lessons learned and disseminating best practices to enhance net utilization have also been
insufficiently prioritized.
Distribution of LLINs should be systematically linked to the simultaneous provision of information and advice,
reinforced by local and national media campaigns. The cultural factors that determine ownership, retention and
use of LLINs, must be taken into consideration to ensure that communication and advocacy activities contribute
to effective use of these nets. In this context, research into local perceptions of mosquitoes, malaria, LLINs and
washing practices is needed to inform the choice of media, messages and communication strategies. The ultimate
aim should include a measurable increase in ITN/LLIN awareness and reported changes in LLIN retention and
use. One key intervention for maximizing net use is the post distribution “hang up” campaign in which volunteers
go door to door and demonstrate how a net is hung and provide additional follow up communication and advice.
Roll Back Malaria partners, including UNICEF, are prioritizing the documentation of lessons learned in
increasing net utilization in order to share best practices.
The Way Forward
Malaria endemic countries in Africa should accelerate current mosquito net distribution efforts to achieve
100% net ownership for all at-risk populations. Priority should be given to documenting best practices to
inform plans to achieve universal coverage and at least 80% utilization by 2010
Countries and funding partners should also prioritise communication strategies to enhance net utilization
in conjunction with national level campaigns
ALMA, working in partnership with UNICEF and other key partners, is prioritizing the collection and
dissemination of best practices in improving net utilization and plans to share this information at the next
ALMA meeting.
“Net maintenance” strategies such as routine distributions, post-campaign “hang-up” visits and periodic
wide-spread messaging should be established to ensure that nets are being used in the years after their
distribution (ie over the entire course of the net’s useful life).