Bed Nets for Malaria Prevention in Western Kenya: Explorations of Care and Repair, Repurposing, and Efficacy of Education Interventions

Abstract

Background: The effectiveness of Long Lasting Insecticidal Nets (LLINs) for malaria prevention is well known. To reach maximum effectiveness and ensure LLIN longevity, households must have access to enough nets, use nets regularly, and maintain nets properly. We aimed to gain a more holistic understanding of LLIN care, misuse, and the educational strategies used to improve these practices through secondary analyses of cross-sectional data in two regions of western Kenya. Factors associated with bed net care and repair practices are not well known. Reports of LLIN misuse are varied, controversial, often rely on self-report, and accurate measurements are needed to maintain political and financial will for LLIN distribution programs. Health education interventions are strategies often used to improve net care, repair, and use practices. However, the effectiveness of these interventions are poorly understood. Additionally, these interventions often have a basis in health behavior theory, but the degree to which education components are informed by education theory is unknown. Methods: We conducted secondary analyses of a cross-sectional study conducted in two areas of differential malaria transmission in western Kenya. We developed a novel bed net care adherence score including items regarding net washing, drying, and physical maintenance to understand the factors associated with net care adherence to recommended practices. Furthermore, we quantified and described observations of alternatively used nets to differentiate between true misuse, defined as the use of an intact net for any purpose other than covering a sleeping space, and potential repurposing of nets. Finally, we performed a systematic literature review of malaria education interventions aimed at improving adherence to bed net care and repair recommendations, with an emphasis on health behavior and education theory. Results: While overall care practices are highly adherent, particularly in the highlands, practices related to daily storage, washing frequency, and drying location need improvement in the lowlands. Seventy-seven percent of nets in the lowlands were washed <3 months prior to the survey compared to 23% of nets in the highlands. More nets were dried in the sun in the lowlands (32% of nets) compared to the highlands (4% of nets). Different elements of care are influenced by various malaria-related attitudes and environmental factors, highlighting the complexity of factors associated with net care. For example, households that learned about net care from community events, that share a sleeping structure with animals, and that have nets used by adult males tend to adhere to washing frequency recommendations. Regarding net repurposing, of 643 households in the highlands we observed 52 (8.1%) with repurposed nets, while 184 (33.0%) of the 574 lowlands households were observed to have repurposed nets. Among the observed repurposed nets, 77.6% of nets in the highlands and 69.8% in the lowlands were repurposed for use outdoors, commonly serving as chicken coops, fences, and tree covers. Repurposed nets found indoors served functions including curtains, covering bathrooms, and cut up and used as washing sponges. In both sites, the vast majority of nets were repurposed because households determined them to be either torn, old and worn out, or both torn and old. We found no impact of net repurposing on malaria prevention efforts. In both sites, there was no association between observed net repurposing and household (1) net ownership, (2) net use, (3) malaria in the last year, or (4) fever in the last two weeks. Net misuse was rare. Of 379 repurposed nets, 4 (1.06%) were in good condition with no holes. O f 1,758 functional nets inside homes, 13 (0.74%) were reported to have ever been used for an alternative purpose. Finally, the systematic review resulted in data abstraction of 29 peer reviewed studies and 289 grey literature records. There were 16 studies with malaria education as a main activity, 10 of which were grounded in theory. There was inconclusive evidence that education on bed net care and repair practices led to improvements in net durability or longevity, and there was no evidence that interventions grounded in theory achieved more positive results. Conclusions: Taken together, the three focus areas of LLIN care and repair, net misuse, and health education interventions advance our understanding of how nets are being maintained and used in field conditions, and the most effective strategies to improve care and repair knowledge and practices. The results of this work will contribute to developing more robust and comprehensive health education interventions in key areas of bed net care and use.