Reported reasons for non-use of insecticide-treated nets in large national household surveys, 2009-2020

Abstract

Insecticide-treated nets (ITN) are the cornerstone of modern malaria vector control, with nearly 3 billion ITNs delivered to households in endemic areas since 2000. ITN access, i.e. availability within the household, based on the number of ITNs and number of household members, is a pre-requisite for ITN use. Factors determining ITN use are frequently examined in published literature, but to date, large household survey data on reasons given for non-use of nets have not been explored. A total of 156 DHS, MIS, and MICS surveys since 2003 were reviewed for questions on reasons why nets were not used the previous night, identifying twenty-four surveys. The percent of nets that were reported used the previous night was calculated for 156 surveys, and frequencies and proportions of reasons for non-use were calculated within the twenty-four surveys. Results were stratified by household supply of ITNs in three categories (not enough”, “enough”, and “more than enough”). The percent of nets used the previous night averaged 70.4% across the 156 surveys conducted since 2003. Reported reasons for non-use of ITNs were primarily nets being extra or being saved for later, followed by low perceived risk of malaria (no mosquitoes/no malaria). The least frequent categories cited as reasons for nets not being used were “net attributes” (size, shape, color, etc) and “fears”. In Senegal’s continuous DHS, the proportions of nets used peaked during high transmission season, while “no/few mosquitoes” responses peaked during the dry season. The proportion of nets used the previous night averaged over 70% from 2003–2020, with no discernible change over this period. Reported reasons for why a net goes unused fell largely into three categories - nets that are extra/being saved for future use; the perception that there is little risk of malaria (particularly in dry season); and “other” responses. Net attributes such as color, size, shape, and texture, and fears related to chemicals were the least frequent reasons given. Classifying reasons for non-use into broader categories facilitates the design of appropriate social and behaviour change interventions to address the major underlying reasons for non-use, where this is feasible.