A photo contest sponsored by the Swiss Malaria Group has stirred some controversy among colleagues. One photo shows a conical net suspended from a tree branch and covering a chicken on the ground, with rocks placed around the edges to ensure the chicken does not escape. The question arising is whether such photos do disservice to malaria control programs and discourage donors, when in fact the net pictured is most likely an old one being re-purposed. Fortunately only a few of the 712 photo entries depict this situation.
There are worries that such photos are fodder for untrained or unscrupulous journalists to derail malaria control campaigns.Â In fact most of the material on net misuse is anecdotal and found in the press and on the web.Â A quick search on PubMed found very few articles that directly addressed the problem. There is more on non-use than misuse.
One well known article appeared in Malaria Journal in 2008 and even had pictures of nets spread on the shored of Lake Victoria as platforms for drying fishing catches. The authors reported that, “The most popular reasons were because the bed nets were inexpensive or free and because fish dried faster on the nets.” They also noted that excess nets had been distributed in the area due to lack of planning and coordination among agencies.
Another article about nets after a major state-wide campaign in Rivers State Nigeria had misuse in its title.Â All houses in the villages had nets after the campaign, but only 72% had any hanging at the time of the survey.Â Twenty percent of these were hung as window curtains (which is in fact another legitimate, though in this care unintended use of insecticide treated materials). Only 38% of children below five years of age had actually slept under a net the night before the survey. In this case non-use was more of an issue that misuse.
The third article dealing with the concept of misuse appeared in PLoS Medicine in 2011.Â The authors faulted the one article they found in peer reviewed publications (the Lake Victoria study mentioned above) for methodological reasons. The authors conclude that, “Inaccurate news stories of widespread ITN misuse should be rebuked directly through the dissemination of empirical data contradicting anecdotal reports and in rebuttal editorials in newspapers and journals.”
Yes, there does need to be better systematic documentation to determine the extent to which new nets are misused and old nets are re-purposed in communities (or even a combination of practices).Â Unfortunately we do have pictorial evidence from the field not long after the 2010 mass distribution of LLINs in Akwa Ibom State where we also had a malaria in pregnancy control program in several local government areas.
The two photos shown here were taken a few months after the campaign and showed clear signs of misuse. This was not a question of re-purposing old nets, since hardly any existed prior to the campaign, and again the staff inspected these directly. In addition to the uses seen here we found new nets being used to cover vegetables to keep off insects as well as used in making goat pens.
Our project in Akwa Ibom had trained volunteer community health workers (CHWs) to provide malaria in pregnancy control services, and they were directly involved in the larger net distribution campaign. These misuse problems were not found in the communities with CHWs.Â The clear lesson to us is that mass distribution without clear follow-up plans in place will result in both non-use and misuse of nets.
Unless donors demand that local health authorities build in a community follow-up component to net distribution, they will indeed be wasting their funds. In the meantime we need to be vigilant and carefully document whether nets in strange places are in fact misused new nets or re-purposed old nets. Re-purposing has an important role to play since safe disposal of old nets is a major environmental concern.