Association between recent overnight travel and use of long-lasting insecticidal nets in rural Uganda: a prospective cohort study in Tororo

Abstract

Background The burden of malaria in Uganda remains high, but has become increasingly heterogenous following intensified malaria control. Travel within Uganda is recognized as a risk factor for malaria, but behaviours associated with travel are not well-understood. To address this knowledge gap, malaria-relevant behaviours of cohort participants were assessed during travel and at home in Uganda. Methods Residents from 80 randomly selected households in Nagongera sub-county, Tororo district were enrolled into a cohort to study malaria in rural Uganda. All participants were given long-lasting insecticidal nets (LLINs) at enrolment and were evaluated every 4 weeks at the study clinic. Participants were asked if they had travelled overnight from their home, and if so, a questionnaire was administered to capture information on travel details and behaviours. Behaviour while travelling was assessed within 4 weeks following travel during the study clinic visit. Behaviour while at home was assessed using a similar questionnaire during two-weekly home visits. Behaviours while travelling vs at home were compared using log binomial regression models with generalized estimating equations adjusting for repeated measures in the same individual. Analysis of factors associated with LLIN adherence, such as destination and duration of travel, time to bed during travel, gender and age at time of travel, were assessed using log binomial regression models with generalized estimating equations adjusting for repeated measures in the same individual. Results Between October 2017 and October 2019, 527 participants were enrolled and assessed for travel. Of these, 123 (23.2%) reported taking 211 overnight trips; 149 (70.6%) trips were within Tororo. Participants were less likely to use LLINs when travelling than when at home (41.0% vs. 56.2%, relative risk [RR] 0.73, 95% CI 0.60–0.89, p = 0.002); this difference was noted for women (38.8% vs 59.2%, RR 0.66, 95% CI 0.52–0.83, p = 0.001) but not men (48.3% vs 46.6%, RR 0.96, 95% CI 0.67–1.40, p = 0.85). In an adjusted analysis, factors associated with LLIN use when travelling included destination (travelling to districts not receiving indoor residual spraying [IRS] 65.8% vs Tororo district 32.2%, RR 1.80, 95% CI 1.31–2.46, p < 0.001) and duration of travel (> 7 nights 60.3% vs one night 24.4%, RR 1.97, 95% CI 1.07–3.64, p = 0.03). Conclusions Travellers, particularly women, were less likely to use LLINs when travelling than when at home. LLIN adherence was higher among those who travelled to non-IRS districts and for more than 1 week, suggesting that perceived malaria risk influences LLIN use. Strategies are needed to raise awareness of the importance of using LLINs while travelling.

Challenges and opportunities for use of long-lasting insecticidal nets to prevent malaria during overnight travel in Uganda: a qualitative study

“…Gender differences were observed in the use of LLINs in lodging places, with females less likely to use those considered of poor quality and unhygienic, compared to males who seemed not to mind. This is consistent with a study conducted in Uganda that showed that women were less likely than men to sleep under LLINs during travel [ 24 ]. The negative perception and cultural beliefs community members held about people who used LLINs, especially during social events, hindered their use.…”

“…Within sub-Saharan Africa, travellers from areas of lower to higher transmission intensity are potentially at high risk of malaria infection and yet use of LLINs during travel is limited [ 24 ]. In this urban population, perceptions, attitudes and experiences were explored regarding use of LLINs for malaria prevention by Kampala residents travelling to other parts of Uganda.…”

East Africa International Center of Excellence for Malaria Research: Impact on Malaria Policy in Uganda

“…in 2012, 4 has materialized into three serial universal LLIN coverage campaigns since 2013, and NMCD has provided platforms and collaborated with PRISM to ensure evaluation of these campaigns. 6 , 49 The LLINEUP and LLINEUP2 cluster-randomized trials provide substantive evidence that NMCD values and supports use of locally generated research findings to inform planning and design of each universal LLIN campaign. 6 , 49 Preliminary work done in preparation for the LLINEUP2 study entailed demonstration of the feasibility of using routine health facility–based surveillance data to generate malaria incidence estimates.…”

Malaria prevalence and long-lasting insecticidal net use in rural western Uganda: results of a cross-sectional survey conducted in an area of highly variable malaria transmission intensity

“…Low perceived risk has been previously documented as a potential barrier to LLIN use [ 45 ]. While staff did not assess travel histories or perform entomologic surveillance [ 46 , 47 ], it is possible that some, if not most, of the infections identified at higher elevations may have been acquired during travel to lower-elevation market areas or social events (i.e., church, weddings). Given the lower prevalence of infection and minimal expected effect of LLINs on travel-related risk, these findings suggest that, at least from an economic standpoint, LLIN distribution at higher altitudes may be an inefficient use of resources.…”