Health Officials commonly berate community members for misusing insecticide treated nets (ITNs) given out during malaria prevention campaigns and programs. Villagers are blamed for doing everything from using nets to catch or dry fish, protect crops or poultry, make football goals and cover their market goods.
For example, The Nairobi Star of 12 March 2012 reported that health officials in Nyanza, Kenya were disturbed that people were using their ITNs to protect their gardens from pests and their kitchens from rodents. The officials threatened to prosecute anyone misusing their nets.
Likewise the Lusaka Times published a story on 10 July 2011 that ITNs were being misused to made wedding dresses/veils and for fishing. “North-Western Province Minister Daniel Kalenga has directed District Commissioners in the province to report any misuse of Insecticide Treated mosquito Nets (ITNs) to the police as it is an offense under the public health Act.” A similar story appeared in April 2014.
There is some theoretical logic to net misuse. Keita Honjo and colleagues concluded from a modeling exercise that, “ITN use for malaria protection can be thwarted in settings of extreme poverty, where an increase in labour productivity by an alternative ITN use can offset the perceived benefits of avoiding malaria infection.”
One has often suspected these challenges to net use border on myth at times. Eisele and colleagues leveled the following critique against the media: “There are a number of potentially damaging misconceptions about insecticide-treated mosquito nets (ITNs) in Africa that have been propagated in media
reports, almost all of which are based on anecdotal accounts.”
Therefore, we were quite interested to learn of a newly published study that analyzed ITN use with “Data from 14 sub-national post-campaign surveys conducted in Ghana, Senegal, Nigeria (10 states), and Uganda between 2009 and 2012 (that) were pooled,” to find out what happens to “lost” nets.
While 16% of 25,447 nets were no longer serving their original purpose, only 6.2% of those were being used for another purpose. Importantly, over 3/4 of those had been damaged prior to re-purposing. The fact that the major reason why nets left the household was because they were given to other users (e.g. relatives) implied that better assessment of community need for nets was required.
In fact re-purposing of old nets may be a natural response to failure of health agencies to devise an environmentally safe way of disposing of ITNs that have passed their natural lifetimes. Therefore WHO recommends that National malaria control and elimination programs should work with national environment authorities work together to ensure proper removal of old nets no longer in use to prevent malaria.
This reassuring article certainly takes precedence over newspaper reports of misuse, but we should still be on the look out for net use problems. A classic example appeared in Malaria Journal in 2008 documenting with data and photos the use of ITNs to dry fish along the shores of Lake Victoria. In that case the root cause of the problem was lack of coordination among agencies such that the villages were supplied more nets than they needed. This appears to have been a one-of-a-kind study.
What is more likely to happen, it seems is that households acquire their nets but for various reasons do not always hang them, as was the case with nearly 30% of recipients in a small study in Rivers State, Nigeria. Malaria control programs need to pay more attention to helping people actually hang and use their nets correctly and regularly than simply being satisfied with reporting the numbers distributed.