Long-lasting insecticide-treated bed net ownership and use among children under five years of age following a targeted distribution in central Uganda

Long-lasting, insecticide-treated bed nets (LLINs) are an important public health strategy for malaria prevention adopted by most countries with endemic malaria. In addition to serving as physical barriers between mosquito vectors and individual users, toxicity and repellency induced by the pyrethroid insecticide-impregnated in LLINs can have important community-wide effects on vector density[1–3], and LLINs have been shown to reduce the burden of malaria, especially among children <five years and pregnant women[4, 5] who are most vulnerable to malaria. LLINs are also one of the most cost-effective interventions, particularly in areas of high-malaria transmission[6].

To increase coverage of LLINs, especially among the vulnerable groups, previous WHO guidelines focused on targeted provision to pregnant women and children <five years especially in areas of high malaria transmission. The Uganda National Malaria Control Programme (NMCP) adopted this policy in 2002 and pursued strategies that included free distribution to pregnant women through antenatal care visits, provision of subsidized nets through the private sector and sale of full-cost nets in the commercial sector. However, despite such endeavours, LLIN coverage in Uganda, as in other countries, fell short of the World Health Assembly resolution targets of 80% bed net coverage by 2010[7]. Based on a Malaria Indicator Survey (MIS) conducted in 2009, LLIN ownership in Uganda was 46% nationwide, with the lowest ownership rate of 22% found in the Central region; LLIN usage among children <five years was even lower, at 32% nationwide and 11% in the Central region[8]. At this time, Uganda had not sponsored any national distribution campaigns, although donors and non-governmental organizations had supported local bed net distributions in areas in which they worked.

With funding from The Global Fund to Fight AIDS, Tuberculosis and Malaria in 2007, the NMCP decided to carry out its first targeted community mass distribution campaign, beginning in the Central region of Uganda, with the objective of increasing LLIN coverage among children <five years and pregnant women to at least 90% by the end of 2010. Before the campaign began, malaria researchers began to advocate for funding for universal distribution campaigns given benefits of universal bed net coverage[9], and WHO issued a position statement in 2007 supporting full coverage of bed nets for all people at risk of malaria[10]. The NMCP decided to implement the campaign in two phases, with the first phase targeting households with vulnerable populations (pregnant women or children <five years) and the second phase filling in the gaps to achieve universal coverage. The first phase began in spring 2010 in the Central region, which had the lowest bed net coverage at the time, as it had not benefitted from any local bed net campaigns previously.

The NMCP, working together with district health management teams and civil society organizations, distributed 1,481,050 LLINs in April and May 2010 in 13 districts of the Central region. Households were initially enumerated and registered by village health teams, and each household was eligible to receive one LLIN for each child under five years and for each pregnant woman. Pregnant women were identified by observation and/or the presence of an antenatal card. To estimate changes in LLIN ownership and usage after the first phase of the bed net distribution in the Central region of Uganda, a survey was conducted from January to February 2011 to compare with data from the 2009 MIS, which was conducted in November-December 2009.

In 2009, the most common source of bed nets was the open market or shops, where nearly half of nets were purchased, but this decreased in 2011 to 25.4% of nets. In 2011, the majority of bed nets (58.6%) were reported to be from the 2010 campaign. Bed net use also increased substantially from only 10.6% of children <five years sleeping under an LLIN to more than half (50.6%) of children in 2011 (Table 1).

Access to LLINs within households, defined as one LLIN per two people[14], increased from 8.5% in 2009 to 25.9% in 2011, but remained low, with only about one-quarter of households having adequate access to LLIN (Table 1). This was even lower (3.6% in 2009 and 22.1% in 2011) when adequate access was defined as the proportion of the population within households having adequate access to LLINs.

This study showed that a targeted community distribution of LLINs substantially increased LLIN ownership and usage in the Central region of Uganda. Households owning at least one LLIN increased by 47%, from 22 to 69%, and LLIN ownership among eligible households was 84%, close to the campaign target of 90%.

Despite remaining gaps, the greatest gains in net usage have been seen after mass community distributions of bed nets[15–19]. Furthermore, such distribution tends to help close equity gaps in bed net ownership and use that existed prior to campaigns[20, 21]. A previous study in Uganda showed that strategies such as socially marketed, subsidized nets alone led to overall low levels of LLIN use among children and inequity in bed net ownership in Uganda[22]. Another study indicated that prior to the campaign, bed net use in Uganda was inequitable, with children in wealthy households significantly more likely to sleep under a bed net the previous night[23]. These results showed that wealth was not associated with either household receipt of a campaign net or with children <five years sleeping under an LLIN the previous night. The only factors this survey found to be significantly associated with LLIN use were the availability of LLINs in the household, measured by the LLIN: household member ratio or access to one LLIN per two people, and, more importantly, receipt of a campaign bed net.

Targeting of bed nets to eligible households was reasonably effective, with 81% of eligible households receiving a campaign bed net compared to 35% of non-eligible households receiving a campaign net. One notable limitation of this study is that the measure of ‘eligibility’ is a proxy, since there was no actual measure of eligibility at the time of the campaign. However, despite potential measurement error introduced by this proxy indicator, the under-coverage of ‘eligible’ households and leakage to non-eligible households is substantial enough to indicate imperfect targeting of households during the 2010 campaign.

Despite large increases in household LLIN ownership LLIN and usage among children <five years old, which was the target of the first phase of the campaign, adequate LLIN access within the household was still very low after the first campaign phase. Nearly three-quarters of household did not have at least one LLIN per two people, which is the current standard for universal LLIN access.

These survey findings show that the first phase of Uganda’s LLIN campaign, which targeted bed nets to households with children <five years and pregnant women, led to substantial increases in bed net ownership and equitable bed net use among children <five years in the Central region. Utilization of LLINs by children <five years increased nearly five-fold, but more work remains to be done to meet the NMCP’s target of 80% for both household ownership of at least two LLINs and 80% of children <five years sleeping under one by 2015. The second phase of the national bed net campaign in Uganda, designed to achieve universal bed net coverage, should help move closer towards that target, and progress should be closely monitored. In addition, continuous distribution strategies, for example through antenatal care, child vaccination clinics, and subsidies for socially marketed nets, among other approaches, should help maintain high bed net coverage in between mass campaigns[10, 17].