Three months after a mass LLIN distribution campaign in Uganda, nearly all households owned at least one LLIN, and six in 10 households owned the targeted number of LLINs (at least one LLIN per two persons in the household). More than eight in 10 residents could sleep under an LLIN if every LLIN in the household were used by two people. However, only two-thirds of residents slept under an LLIN the previous night. LLIN ownership was associated with belief in their protectiveness against malaria, and LLIN use was associated with net age.
Currently, the targets in the NMCP strategic plan for households with at least one LLIN and proportion of people sleeping under LLIN were set at 80% . The WHO also calls for procuring LLINs with the goal of providing each household with one LLIN for two persons . These expectations could create a feeling of failure since 64% households had at least one LLIN for two people, falling below the target. However, recent literature shows that a target of 80% for households owning at least one LLIN for two people is not achievable at a national or even sub-national level . The proportion of the population with access to an LLIN within the household is the key indicator of universal coverage . This study showed that more than eight in 10 residents could sleep under an LLIN if every LLIN in the household were used by two people.
Beyond achieving universal coverage, a related metric of success after a mass distribution campaign is the proportion of household members sleeping under the LLINs . This study showed an increase in the proportion of the population that slept under an LLIN the previous night from 59%, reported in UMIS 2018/19, to 69% after the 2021 mass distribution campaign. However, this achievement also falls short of the NMCP target of having 85% of the population sleeping under an LLIN . Some reasons that people may not use nets, even when they are provided, include lack of sufficient space to hang the net, discomfort with the net material, belief that there are harmful chemicals in new LLINs, and a desire to save LLINs for use when a household member is pregnant [3, 7]. This study showed that older nets were more likely to be used than the newest nets, the preference for polyester LLINs was slightly lower than that for polyethylene LLINs, and there was an increased use of LLINs among people who believed that they were protective against malaria. There is evidence that behavioural change communication (BCC), either through mass media , intensive and repeated inter-personal communication, or material incentives  can promote changes in behaviour, beliefs and attitudes towards LLINs . While BCC through mass media is the main approach used in Uganda , more data are needed to identify the optimal mix of approaches to maximize LLIN use after mass distribution campaigns.
This study showed that inequality in LLIN ownership between households with low and high wealth indexes was minimal. The minimal inequality observed in this study could be due to improved coverage on LLINs. However, this analysis is not based on randomly selected sample for the household and some districts may be more affluent than others, this could potentially lead to bias in these results. A study evaluated the change in equity in ownership of LLINs in 19 sub-Saharan African countries and concluded that equity of net ownership had improved in 13 countries, including Uganda, after mass distribution of LLINs . The ownership of at least one LLIN was lower among households where respondents reported using mosquito repellents, compared with those that did not use repellents. Respondents who had repellents may have believed that repellents were protective enough and they did not need LLINs; however, it is also possible that people who did not receive or have enough LLINs may have used repellents as an alternative. While mosquito repellents do provide protection against malaria infection [18, 19], the combined use of mosquito repellent during evening outdoor activities followed by the use of LLINs during bedtime at community level significantly reduces malaria infection compared with repellent use alone . Both education and BCC may be required during LLIN distribution to ensure that repellents are used as adjuvants, not substitutes, for LLINs.
This study has some limitations. First, LLIN use was self-reported, which could have underestimated or overestimated the actual use of LLINs. Second, reported use of LLINs the night before the survey only captures use at one point in time and might not represent regular use. Although this is the recommended approach to measuring LLIN use , a meta-analysis showed that self-reported measures overestimate LLIN adherence by 13% relative to objective measures , suggesting that the true proportion of the population who slept under LLIN the previous night could be lower than what this study estimated. Third, ability to understand why individuals chose to use nets or not is limited by the quantitative nature of the questionnaire. Further exploration using qualitative research methods would be required to better understand local perceptions and why they are hesitant to take up new LLINs. Fourth, the overall sample for the survey only included one sub-county, one parish, and two villages per district, which may not be representative of the district as a whole. If these sampling units in the district are not homogeneous, this could potentially lead to bias in any direction in results. This approach was employed because of limited resources and to get the broadest sample possible geographically.