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

Net usage

Net use behaviour reportedly varied amongst respondents, and ranged from consistent
use to seasonal use to, in two cases, non-use. More than half of all households reported
that all family members slept under nets most of the time. VHTs across strata suggested
that community members regularly used their nets even when sleeping outside their
homes, such as children at boarding schools or fishermen sleeping close to lake shores.
In households where not all members slept under nets, this was mostly due to an insufficient
number of nets, a growth in family size, households having not received enough nets
during the UCC, or nets having since been destroyed or lost. Common household responses
to an inadequate number of nets were the further sharing of sleeping spaces, or the
prioritizing of family members, usually children or pregnant women.

Seasonal use of LLINs was reported across strata, and appeared to relate to the fluctuating
visibility of mosquitoes and, therefore, perceived malaria threat, a decline or rise
in local malaria cases, and seasonal temperature change which affected levels of comfort
experienced when sleeping under the net.

“We were given these nets during the rainy season when there were a lot of mosquitoes.
I hung the nets and the children slept in them that time. When the rainy season was
over, we removed the nets because during that time there were no mosquitoes.” (Male,
Bugana village, Buliisa).

Net use appeared to be more consistent amongst settled urban and rural communities
compared with fishing, pastoralist, and refugee/immigrant communities, where a number
of respondents raised problems in hanging nets in round houses and a lack of proper
sleeping beds, which in some cases reportedly led to nets tearing. In Piida A (a fishing
village) and Kasonga (a refugee settlement), all household members used a net in just
two of the five households, compared with Mpunda (rural poor community) where all
members used nets in four out of five households, and Kijungu A (an urban wealthier
site) where all members reportedly used nets in all households. The data suggested
limited movement of nets across households (‘intra-household exchange’), with only
two households having given away nets to other people.

Although reports were not widespread, there were some cases of nets being used for
other purposes such as for fishing, drying silver fish, fencing for domestic animals,
construction of bath shelters, fencing or shades for plants, and for make-shift curtains.
Such cases were more common in fishing, pastoralist and immigrant communities. There
was some but limited suggestion of nets from the UCC being sold to make money, though
it was not clear whether these nets were in fact excess nets, and individuals who
used nets for other purposes in fact also used them for malaria protection at home.

“There are people on landing sites who use nets for fishing. Some people sell nets
in order to get some money while other people use nets to guard their crops from animals
and other pests. People say that since these nets are treated, they are capable of
chasing away animals.” (Male, Nsanje village, Kiboga).

Overall, experience in using nets before the UCC appeared to contribute to people’s
tendency to use nets in the long-term, seemingly because they have had more time to
appreciate the benefits of net use, or simply because net use was already a more entrenched
practice.

“Everyone in this family has a net and they all sleep under these nets because even
before the government nets came, we had nets for everyone in the family so there has
been no change.” (Female, Kayanja village, Kiboga).

“I grew up seeing my parents and all of us in our home sleeping under the nets so
it was something I had to emulate and practice when I got my own family” (Female,
Toonya Village, Hoima).

Perceived benefits of net use

Across strata, perceived benefits of net use appeared key in encouraging the consistent
use of nets over time and, as expected, principally related to the prevention of mosquito
bites and malaria. Similarly, previous bad experiences with malaria appeared to reinforce
the incentive to continue using nets. Some households mentioned a seemingly comparative
ineffectiveness of other malaria preventive methods used prior to receiving nets such
as sprays, coils or slashing the compound, which appeared to have boosted their focus
on and use of nets.

“When we slept in those nets that (first) night, me, my husband and the children …we
slept comfortably because the mosquitoes didn’t get close to us – they had no chance
to bite us. Even now, as we continue to use these nets, the situation is still the
same as it was when we slept in these nets for the first time.” (Female, Ngwendo Farm
village, Buliisa).

“Before the introduction of nets, we were using other methods of fighting malaria
which included lighting a candle at night to chase away mosquitoes, slashing around
the compound and clearing any stagnant water near the house. Despite the efforts,
all these methods failed to reduce malaria and that is when we decided to use nets…
Malaria has now reduced due to the use of nets.” (Female, Kidoma village, Hoima).

Beyond protection from malaria, additional benefits of net use most commonly mentioned,
and which appeared to drive consistent use, included providing a barrier against other
insects such as cockroaches, protection against falling grass and other debris from
the roof, the warmth provided by nets (in some cases reducing the need for a blanket),
less sleep disturbance and overall better skin and general health. The reduction in
malaria was also reported to have afforded household members more time to work in
their gardens or perform other income-generating or household duties. A few respondents
also noted the aesthetic benefit of a net hung above the bed.

“The mosquitoes and insects which used to bite us or fall on us while sleeping, these
days I don’t see them … so we sleep comfortably. We have peace now because the skins
of my children are healthier and no longer have scars of mosquito bites. …sleeping
under nets has increased my time to go to my gardens and do my domestic work without
being tired and stressed.” (Female, Kidoma village, Hoima).

Social support and influence

Household heads and/or caregivers tend to allocate sleeping spaces and nets and, in
that sense, were found to be in a strong position to influence net use. Their level
of enthusiasm in encouraging members of the household, particularly children, to sleep
under a net was found to be important in either boosting or reducing net use over
time.

“Some children sleep carelessly, others sleep and kick these nets while sleeping and
so as a parent I am forced to frequently wake up at night to check whether they are
still sleeping in the nets and if not I have to cover them properly.” (Female, Nyeramya
village, Buliisa).

While personal or household experience in using nets seems to have been a key driver
in promoting consistent net use, respondents were asked about any people or groups
in their community who had appeared to encourage or discourage the use of nets. Encouragement
for net use reportedly came mainly from village leaders (“local council [LC] 1 s”)
and VHTs, who promoted net use at village meetings and conducted home visits where
they would offer direct support in hanging and using the net. Government officials,
religious leaders, health workers, neighbours, as well as non-governmental organization
project staff were also mentioned in encouraging net use. Radio stations were also
reported to have programmes and advertisements promoting net use. A small number (three)
incidences were mentioned where people had seemingly discouraged net use through rumours
or the sharing of bad experiences, largely relating to health concerns from the insecticide
in the nets.

“A few days after were had hung the nets we got a rumour that these nets had medicine
which could make us sick. This prompted us to remove the nets immediately. We put
them back to their polythene packages and kept them in a safe place…It was [a] rumour
circulating in the village know who was saying it. At a later stage,
I realized it was a lie and my children resumed using the nets.” (Female, Bukomero
A village, Kiboga).

Net condition

As expected, people were more likely to use a net if it remained in good condition
and less likely if it had developed holes or was torn and thus was deemed less effective
in protecting them from malaria. Some respondents across strata mentioned that net
condition had deteriorated over time as a result of poor bedding materials, such as
papyrus reed mats, or rats. Few respondents (three) mentioned actual repair efforts
though VHTs, more than household heads and caregivers, indicated a willingness to
repair their nets to enable continued use. Among those who made attempts to repair
the nets, it appeared that usage was only stopped when the net was considered beyond
repair.

“I no longer use my net because it got holes and many mosquitoes started entering
in it and I decided to remove it completely from my bed. …It is my grandchild who
burnt many holes into my net. He was playing with a matchbox…it was hard for me to
repair. That is when I decided to remove it.” (Female, Bugana village, Buliisa).

Availability and purchase of replacement nets

Across the different strata, and thus across a range in terms of access to services
and potential ability to pay, once nets were considered old or damaged and thus less
effective, people tended to stop using them or instead switched to untreated nets
rather than source new LLINs. There were no examples of households having replaced
their nets through the purchase of new LLINs using their own resources. This is despite
some informants having bought nets before the UCC, although the proportion of those
having been LLINs is likely to have been low. The few households which reported having
acquired replacement nets on their own had bought untreated nets. When asked what
they would do when their nets grew old, the most common response across strata was
to wait for another free net rather than replace the net themselves; as well as the
expectation of further net donations, an overall lack of funds and low availability
through the local commercial sector appeared to contribute to this response.

“When the nets I have are worn out or even get burnt, I would inform the village leader
who will inform the administrators to get us new nets. If we don’t get nets from the
donors it would be difficult for me to buy a net because I don’t have money to buy
a net.” (Male, Kasonga village, Hoima).

“When the mosquito nets grow old, I will not buy nets because in the community there
are no shops which sell nets. That is why am requesting the government to give us
more nets. Secondly, so many organizations have been giving us free nets so if I buy
any net I would be wasting money – I know they will keep coming to give us nets.”
(Female, Piida A Village, Buliisa).

Other factors influencing net use

Other practical factors that appeared to influence net use, though perhaps more in
the initial phase post-distribution than over the long-term, included an inadequate
space to hang the net (i.e. small houses or bedrooms), a lack of proper beds (difficulties
in spreading and tucking in nets when sleeping on the floor), and challenges in hanging
rectangular nets in circular houses. Some households had also switched from LLINs
to untreated nets due to perceived dangers or irritations with the insecticide in
the LLINs, or because the netting material was perceived to be too coarse.

Changes in net use experiences over time

Asked specifically about their household’s recent experiences in using nets compared
with when they first received them, most respondents, across strata, relayed positive
experiences, with few changes in net use experience over time. Many did mention though
that nets became less potent and thus less effective over time causing the amount
of visible mosquitoes in the house to rise again.

“Nothing has changed. I still use [nets] in the same way like I did in the past. What
I can say is that now the nets are no longer that effective and mosquitoes enter and
bite my children at night.” (Female, Kijungu village, Hoima).

Most significant change story selection and summative analysis

The story selection process followed three distinct stages with different groups of
stakeholders (Table 2). The emphasis of the selection process was to establish what was considered significant
in the changes reported and why, and thus selection was based on criteria generated
inductively. These included: (i) stories that went beyond just malaria prevention
and included wider social and economic benefits at the household level, (ii) stories
that illustrated emotional and personal feelings (impacts) about the changes being
reported; (iii) stories that explained the changed situation before and after use
of LLINs, and (iv) stories that included reference to severe malaria. Of interest
was that stakeholders at each selection stage adopted similar reasoning for the selection
of stories. Stakeholders at all selection stages were particularly responsive to emotive
stories in terms of suggesting them as ‘significant’.

The ‘significant changes’ reported to have resulted from the use of nets were wide-ranging
and spanned direct health benefits, as well as economic, social and emotional benefits,
felt at both individual and household levels. The three MSC stories finally selected
(the final group were unable to agree on one MSC story from the three remaining) all
reflect this range of benefits (Fig. 1), available in full (Additional file 1). The VHTs, in addition to the benefits to them as individuals and their families,
spoke of community-wide and health system changes, such as reduced stock outs of anti-malarial
drugs and shorter patient queues at health centres.

Fig. 1. Summaries of most significant change (MSC) stories selected

A summative analysis approach was also taken to review the frequency of most significant
changes experienced from using nets since the UCC as mentioned across all MSC stories
(Fig. 2). Overall, ‘fewer malaria cases’ was the most commonly mentioned change reported,
corresponding with findings from the thematic analysis which suggested prevention
of malaria as a key driver for consistent use. This was followed by ‘better overall
health’ and ‘money savings from less need to access care/treatment for malaria’. ‘Peace
of mind/less stress’ was the next most commonly mentioned change, an aspect also highlighted
through the story selection process. These changes, and others, were all mentioned
more frequently than ‘reduced severity of malaria’, though this would have been covered
in part through ‘fewer malaria cases’. ‘Acting as a physical barrier from other insects
or substances’ (i.e. debris) was mentioned less frequently than may have been anticipated
from the results of the thematic analysis. In general, there appeared to be little
difference in terms of the most commonly mentioned changes reported across strata,
which corresponds to little variance in factors driving consistent net use across
strata as reported from the thematic analysis.

Fig. 2. Frequency of ‘change’ mentions across all MSC stories

Positive deviance analysis

Patterns of net use behaviour varied widely from cases where all household members
consistently used nets to cases where whole families had abandoned net use (these could
be seen as negative deviants). Discussion gave focus to past (pre-distribution), current,
and intended (future) behaviours as relating to consistent net use (Table 3). Characteristics of positive deviant respondent households (keen users) included
having previously used nets before the UCC, use of nets throughout seasons, the adapting
of sleeping spaces to enable covering of all family members, response to challenges
to enable regular net use, motivation of others to use and care for their nets and
they generally described nets as being an integral part of their lives. They also
intended to continue using nets and would be willing to purchase a replacement. Many
of these behaviours appeared to be mutually reinforcing i.e. family members share
sleeping spaces so all members can sleep under a net each night and because net use
has become habitual, it follows naturally to encourage or support others in using
nets.

Table 3. Common characteristics of positive deviants