The importance of education to increase the use of bed nets in villages outside of Kinshasa, Democratic Republic of the Congo

Malaria is one of the leading causes of morbidity and mortality in the Democratic Republic of the Congo (DRC), with approximately 180,000 deaths attributed to malaria each year [1]. This is one fifth of the 863,000 malaria deaths reported worldwide by the World Health Organization in 2008 [2]. The large number of malaria cases in the DRC is due to high malaria transmission rates, and it is exacerbated by two decades of civil war that have decimated the health care infrastructure and the government's ability to deliver social services.

Insecticide-treated bed nets offer essential protection against mosquitoes and significantly reduce morbidity and mortality due to malaria, particularly in endemic areas [3, 4]. The DRC government distributed nearly 11.2 million long-lasting insecticide-treated nets (LLINs) free of charge between 2006 and 2008. This campaign provided LLINs to only 30% of the households and 24% of children younger than 5 years old [5]. To boost bed net coverage, the National Malaria Control Programme (NMCP) in the DRC planned to distribute an additional 2 million LLINs to cover at least 4 million people in Kinshasa and its surrounding villages in 2008.

Attempts to use bed nets are often hampered by environmental, social, and cultural considerations. Potential factors that affect bed net use are education level of family head, wealth, colour and shape of bed nets, house structure, sleeping arrangement, distance to retail stores and cultural taboos [6–9]. Even though LLINs have gained popularity, the effectiveness of LLINs against malaria transmission will be impaired without their proper use. Studies have shown that owning LLINs does not always increase the prevalence of use [10–13]. For instance, nets are occasionally misused for other purposes such as fishing in villages near Lake Victoria [14]. Little information is available about bed net use in the DRC, with the exception of a few studies on bed net use by women and children in Kinshasa before the mass distribution [15–17]. This study was designed to investigate availability and use of bed nets after the recent mass distribution in the villages outside Kinshasa and to determine the factors affecting bed net use.

The GLMM revealed that age was significantly associated with individual bed net use, but the variables of sex and village were not associated (z = -5.09, p < 0.001). Bed nets were used by over 90% of children 5 to 15 years of age, whereas less than 50% of the residents in other age groups used bed nets (Figure 1).

Household bed net use was examined using six variables: bed availability, bed net availability, house size, number of rooms, head of household's education level, and village (Figure 2). The three variables of net availability, house size, and village were not included in the final model. Bed availability (z = 3.77, p < 0.001), education level (z = 2.29, p = 0.022), and number of rooms (z = 3.81, p < 0.001) were significantly associated with bed net use at the household level. Net use was also significantly associated with the interaction between bed availability and the number of rooms (z = -2.56, p = 0.011).

A total of 66 interviewees provided reasons why they did not use bed nets. The most common reason (26 cases, 39.4%) was related to heat discomfort within a bed net. Twenty-two (33.3%) respondents believed that females become infertile under a bed net. Two other reasons included associating bed net use with sleeping in a coffin (nine cases, 13.7%) and the idea that the bed net campaign was a plot by the United States of America Central Intelligence Agency to reduce the African population by treating bed nets with a chemical that kills sleepers (eight cases, 12.1%).

The number of bed nets reported was enough to cover all the villagers, apparently a result of the recent NMCP campaign. Nevertheless, fewer than half of the nets were used, and half of the villagers did not sleep under the nets. A recent study reported that the prevalence of bed net use is 56% in Nigeria and over 90% in Senegal [10]. Thus, the proportion of nets used in the villages of the DRC is considerably lower compared with other African countries, and this may hamper the effectiveness of the malaria prevention campaign.

The most common reason given for not using bed nets was discomfort due to heat within the net. This reason was also common in other African countries [6, 10, 20, 21]. The other reasons given were based on cultural myths, and failure to use bed nets is often associated with misconceptions and cultural taboos [22]. Discomfort due to the heat may also be a misconception; although the bed net may reduce airflow and increase temperature, the increase might not be noticeable, and if it is noticeable, one's health should not be comprised due to discomfort.

Education about malaria transmission and the benefits and proper use of bed nets should eliminate the misconceptions about bed nets usage. Results reported here demonstrate that the education level of the family head of household was associated with bed net use among family members in the surveyed villages. A previous study in Kinshasa also reported that women who had secondary school or higher education were 3.4 times more likely to own and 2.8 times more likely to use a bed net compared with women with less education [15]. A mother's education level and adequate knowledge about malaria transmission are also associated with their use of bed nets in other countries [21–23]. As a majority of children less than 5 years of age sleep with their parents in Africa, their protection from malaria depends on parents' perception of bed nets [24, 25].

This study also found a lower prevalence of net use among children less than 5 years of age and among adults, and a greater prevalence of use among school children 5 to 15 years old. This result was unexpected, as several studies have reported lower use of bed net use among school children [9, 21, 25, 26]. Mothers and infants are primary targets for net distribution, and their use of nets should be high [15, 17]. In recent years, primary and secondary schools have focused on education in disease prevention and sanitation, including bed net use in the district where the surveyed villages in this study are located. This systematic education program may explain the high prevalence of nets use among children 5 and 15 years of age in these villages.

The other important factors associated with bed net use were the numbers of beds and rooms in the house. These results are comparable to those from other studies [21, 27]. As the number of rooms increased, the role of each room became clearer: it is common to use one room as a living room when a house has more than two rooms, and the others as bedrooms [9, 27]. Residents who sleep on the floor in living rooms would have less attachment to nets compared with nets hung over beds in bedrooms, as the living room nets are most likely taken down every morning. Consequently, having more bedrooms increases both privacy and the space available for beds, which in turn increases the number of sites that are suitable for hanging nets, thereby increasing net use.

Assessed the reasons for not using bed nets, the greater use of nets among school children and the importance of education level of family head, it is evident that education was the most important factor affecting bed net use in the villages outside Kinshasa. Development of an educational programme, particularly one directed toward parents, is necessary to reduce misconceptions and increase prevalence of bed net use among all age groups.