Background
Methods
Ethics statement
Study settings
Sub-location, Province | Estimated population sizea
| Estimated average yearly malaria incidenceb
| Altitude range | Household bed net ownershipa (%) | Malaria transmission pattern | Description of environment |
---|---|---|---|---|---|---|
Highland site: Tindinyo, Chepsonoi, and Kiborgok sub-locations, Kapkangani, Nandi North, Rift Valley Province | 12,300 | 35 per 1000 | 1600–2100 m | 37 | Seasonal after short and long rains | Primarily rural, bisected by major highway with some commercial shops along roadside; permanent and semi-permanent streams; tea, maize |
Lowland site: Kabar East and Kabar West, Nyanza Province | 4300 | 400 per 1000 | 1100–1200 m | 52 | Holo-endemic – year round high levels of transmission with seasonal peak following the rains | Rural; agriculture (maize, rice, sugarcane); less animal husbandry than Kapkangani |
Bed net terminology
Community forum methodology
Sampling
Key themes | Sub-themes | Focus groups reporting theme | Representative quote |
---|---|---|---|
Access | Distance | H2, H3, L10 | “The health clinic is far from the community members, up to 7 km, therefore going to buy a net is far and it leads to impulse buying of other items needed.” H3 |
Cost | H1, H2, H3, H5, L9 | “Once distributed to the people on warranty no chances of getting replacement unless you dig deep into your pockets.” L9 | |
Age-restrictions | H1, H2, H3, H4, H5, H6, L10 | “There are problems getting a bed net because they are only given at the health facility on the condition that they belong to pregnant women and children under 5 years” H5 | |
Stock-outs | H1, H3, L7 | “The greatest problem is that statistics taken for bed net supply doesn’t correspond to the actual nets brought for distribution hence most people don’t get the bed nets.” L7 | |
Replacement | H1, H6 | “In some region the bed nets are sold and others given freely.it therefore kill the morale of others to acquire the nets.” H6 | |
Effectiveness | Wears out too soon | H1, H2, H4, H5, L7, L8, L9, L10 | “After the washing of the nets the effectiveness of the mosquito repellant fade away and that make it not effective.” L7 |
Difficult to maintain/damage easily | H1, H2, H3, H6 | “Most nets get burned with tin lamps creating a hole making the net not effective to use” H3 | |
Quality of distributed nets | H2, L8, L9 | “Some of the nets have less effective chemical repellent since they are not retreated and are [ineffective] even though not in bad condition” L9 | |
Side effects | Suffocation | H2, L7, L8, L10 | “It also suffocates small children and leads to difficulty in breathing.” L7 |
Heat | H4, L8, L10 | “We don’t always use a bed net because during the dry spell season it is hot and people do not use the bed net.” H4 | |
Rash/allergy | H1, H2, H3, H4, H5, H6, L7, L8, L9, L10 | “Once one gets into contact with the net which the repellant is still strong, the skin rashes are developed causing discomfort to the skin.” L7 | |
Family planning | H2 | “The belief that the chemical in the bed net is for family planning [keeps them from using it]” H2 | |
Bad dreams | H4 | “Sleeping under a bed net gives one to dream bad dreams.” H4 | |
Lack of knowledge | Don’t understand transmission or importance of using bed net | H1, H2, H4, H6 | “[In our] culture [we] believe that we used to sleep without nets why use it now?” H2 |
Not aware of how to maintain bed net | H1, H2, H3, H4, H6, L7, L8 | “Those who distributed them never taught us how to use them.” L8 | |
Use for other purposes | H1, H2, H4, H5, H6 | “A bed net is a multi-purpose item. Some use it for decoration and curtains, fishing, rope to tie animals.” H4 | |
Logistical/convenience | Hanging | H1, H2, H3, H4, H5, H6, L7, L8, L9, L10 | “Hanging a bed net is a problem especially one without a ring. It is difficult because at night when you are tired you simply sleep.” L10 |
Not attractive | H1, H2 | “Some people are attractive to certain colours when a bed net is dull they don’t go for it.” H1 | |
Difficult to keep clean | L8, L10 | “They become dirty very easily and they are difficult to [re]hang” L10 | |
Sleeping space too small | H1, L8 | “Squared bed net consume space therefore some rooms are not enough.” H1 | |
Believe only for use with bed | H3, H4 | “Some believe that bed net is used only on bed net on sleeping on the floor.” H3 |
Community forum administration
Qualitative data analysis
Cross-sectional survey methods
Sampling
Data collection
Data preparation and statistical analysis
Results
Community forum
Community forum characteristics
Access issues
“There are some problems getting a bed net because they are only given at the health facility on the condition that they belong to pregnant women and children under five years”.
“Due to economic pressure people consider buying food stuff rather than buying a bed net”.
“The health clinic is far from the community members, up to 7 km, therefore going to buy a net is far and it leads to impulse buying of other items needed”.
“The greatest problem is that statistics taken for bed net supply doesn’t correspond to the actual nets brought for distribution hence most people don’t get the bed nets”.
“Once distributed to the people on warranty no chances of getting replacement unless you dig deep into your pockets”.
“In some region the bed nets are sold and others given freely. It therefore kills the morale of others to acquire the nets”.
Side effects
“Once one gets into contact with the net when the repellant is still strong, the skin rashes are developed causing discomfort to the skin”.
“It also suffocates small children and results into difficulties in breathing”.
“We don’t always use a bed net because during the dry season it is hot and people do not use the bed net”.
“The belief that the chemical in the bed net is for family planning [keeps them from using it]”.
“Sleeping under a bed net gives one to dream bad dreams”.
Effectiveness
“Some kinds of the nets have less effective chemical repellent since they are not retreated and are [ineffective] even though not in bad condition”.
“After the washing of the nets the effectiveness of the mosquito repellant fades away and that makes it not effective”.
“Most nets get burned with tin lamps creating a hole making the net not effective to use.”
Lack of knowledge
“[In our] culture [we] believe that we used to sleep without nets why use it now?”
“Some don’t really believe that mosquito bites from infected mosquito causes malaria leading them not to use bed net”.
“A bed net is a multi-purpose item. Some use it for decoration and curtains, fishing, rope to tie animals”.
Logistics
“Hanging a bed net is a problem especially one without a ring. It is difficult because at night when you are tired you simply sleep”.
“Some believe that a bed net is used only on bed not on sleeping on the floor.”
“They become dirty very easily and they are difficult to [re]hang”.
Cross-sectional survey results
Demographic and malaria knowledge, attitude and practice differences between sites
Characteristic | Highland (n = 1923) | Lowland (n = 1332) |
---|---|---|
Demographics | ||
Children under five in household | 1026 (53 %) | 323 (25 %) |
Pregnant woman in household | 107 (11 %) | 163 (12 %) |
Female household head education level | ||
No school | 211 (11 %) | 170 (13 %) |
Primary | 1107 (58 %) | 601 (45 %) |
Secondary | 505 (27 %) | 446 (34 %) |
More than secondary | 90 (5 %) | 115 (9 %) |
Durable good ownership | ||
Radio | 1620 (84 %) | 1019 (77 %) |
Stove | 124 (7 %) | 169 (13 %) |
TV | 367 (19 %) | 443 (33 %) |
Indoor lighting | 54 (3 %) | 149 (11 %) |
Bike | 298 (16 %) | 709 (53 %) |
Sofa set | 795 (41 %) | 626 (47 %) |
Bed set | 1652 (86 %) | 1240 (93 %) |
Wealth group | ||
Very low | 906 (47 %) | 340 (25 %) |
Low | 390 (20 %) | 120 (9 %) |
Medium | 292 (15 %) | 407 (31 %) |
High | 332 (17 %) | 465 (35 %) |
Basic malaria knowledge | ||
Malaria transmitted by mosquitoes | 1910 (99 %) | 1319 (99 %) |
Fever a symptom of malaria | 1845 (96 %) | 1320 (99 %) |
Malaria prevented by bed nets | 1876 (98 %) | 1322 (99 %) |
Attitudes about malaria | ||
Family at risk of malaria | 1871 (97 %) | 1274 (96 %) |
Malaria is serious | 1751 (91 %) | 1233 (93 %) |
Children are more at risk than adults | 1632 (85 %) | 877 (66 %) |
People in my community concerned about malaria | 1881 (98 %) | 1267 (95 %) |
Malaria history | ||
Known someone who died of malaria | 1025 (53 %) | 777 (58 %) |
Known someone with severe complications of malaria | 687 (37 %) | 537 (41 %) |
Known someone who had long-term sequaelae from malaria | 167 (9 %) | 128 (10 %) |
Attitude towards bed nets as a prevention strategy | ||
Community believes bed nets are good way to prevent malaria | 1797 (94 %) | 1311 (98 %) |
Community rather buy other things than bed net | 425 (22 %) | 161 (12 %) |
Community thinks bed nets purchased better than free | 308 (16 %) | 252 (19 %) |
Householder believes bed net is beneficial | 1809 (94 %) | 1317 (99 %) |
Bed nets are a good way to prevent malaria | 1667 (87 %) | 1295 (97 %) |
Householder believes bed nets bought are better than free | 258 (13 %) | 183 (14 %) |
Attitudes towards bed net access | ||
Same chance of obtaining a bed net | 1618 (84 %) | 1167 (88 %) |
Bed net is easy to get | 474 (25 %) | 594 (45 %) |
Could not afford a bed net if had to pay | 632 (33 %) | 219 (16 %) |
Attitudes towards bed net use | ||
People in community only use during rainy season | 335 (17 %) | 28 (2 %) |
Householder only uses during rainy season | 171 (9 %) | 29 (2 %) |
No use using a net, I will get malaria anyway | 235 (12 %) | 32 (2 %) |
Using malaria drugs is easier than using bed net | 284 (15 %) | 154 (12 %) |
Using a bed net is difficult | 241 (13 %) | 36 (3 %) |
World Health Organization bed net use indicators
Differences in associated ownership factors
Highland seasonal transmission adjusted OR (95 % CI) (n = 1923) | Lowland holo-endemic adjusted OR (95 % CI) (n = 1332) | |
---|---|---|
Demographics | ||
Children under five in household |
1.8 (1.5, 2.3), p < 0.0001
|
1.6 (1.2, 2.1), p = 0.0007
|
Pregnant woman in household | 0.8 (0.6, 1.1), p = 0.37 | 1.4 (1.0, 2.0), p = 0.08 |
Female household head education level | ||
No school | Ref | Ref |
Primary |
1.7 (1.2, 2.5), p = 0.005
| (0.7, 1.6), p = 0.65 |
Secondary |
2.3 (1.5, 3.4), p < 0.0001
| 1.1 (0.7, 1.6), p = 0.75 |
More than secondary |
3.8 (2.1, 6.9), p < 0.0001
| 1.6 (0.9, 2.9), p = 0.10 |
Durable good ownership | ||
Radio |
0.7 (0.6, 1.0), p = 0.05
| 1.2 (0.9, 1.7), p = 0.22 |
Stove | 1.7 (1.0, 2.7), p = 0.06 | 0.8 (0.5, 1.5), p = 0.32 |
TV | 1.2 (0.7, 2.1), p = 0.44 | 0.8 (0.5, 1.5), p = 0.62 |
Indoor lighting | 1.1 (0.6, 2.1), p = 0.70 | 1.5 (0.9, 2.3), p = 0.09 |
Bike | 0.9 (0.6, 1.3), p = 0.51 |
1.5 (1.2, 1.9), p = 0.002
|
Sofa set | 0.9 (0.6, 1.5). 0.68 | 1.0 (0.7, 1.4), p = 0.92 |
Bed set |
0.4 (0.3, 0.6), p < 0.0001
|
1.8 (1.1, 3.0), p = 0.01
|
Wealth group | ||
Very low | Ref | Ref |
Low | 1.4 (0.8, 2.4), p = 0.23 | 1.0 (0.6, 1.8), p = 0.97 |
Medium | 1.5 (0.9, 2.6), p = 0.10 | 1.0 (0.6, 1.8), p = 0.96 |
High | 2.1 (0.8, 4.8), p = 0.10 | 1.1 (0.5, 2.4), p = 0.79 |
Malaria knowledge | ||
Malaria transmitted by mosquitoes | 1.3 (0.3, 5.4), p = 0.68 | 0.3 (0.04, 2.5), p = 0.27 |
Fever a symptom of malaria | 1.4 (0.8, 2.6), p = 0.25 | Undef. |
Malaria prevented by bed nets | 1.5 (0.6, 3.5), p = 0.34 | Undef. |
Malaria perception of risk | ||
Family at risk of malaria |
3.5 (1.5, 8.2), p = 0.004
| 0.6 (0.3, 1.2), p = 0.16 |
Malaria is serious |
2.7 (1.7, 4.1), p < 0.0001
| 0.8 (0.5, 1.4), p = 0.45 |
Children are more at risk than adults | 1.1 (0.8, 1.5), p = 0.62 | 0.9 (0.6, 1.2), p = 0.35 |
People in my community concerned about malaria |
0.4 (0.2, 0.8), p = 0.01
| 0.5 (0.3, 1.1), p = 0.09 |
Malaria history | ||
Known someone who died of malaria |
1.3 (1.0, 1.6), p = 0.03
| 0.8 (0.6, 1.1), p = 0.17 |
Known someone with severe complications of malaria |
1.3 (1.0, 1.7), p = 0.02
| 1.3 (0.9, 1.7), p = 0.15 |
Attitude towards bed nets as a prevention strategy | ||
Community believes bed nets are good way to prevent malaria | 1.0 (0.6, 1.7), p = 0.90 | 1.3 (0.4, 2.8), p = 0.63 |
Community rather buy other things than bed net | 0.8 (0.6, 1.0), p = 0.07 |
0.6 (0.4, 1.0), p = 0.04
|
Community thinks bed nets purchased better than free | 1.0 (0.6, 1.9), p = 0.93 | 1.5 (0.9, 2.3), p = 0.09 |
Householder believes bed net is beneficial | 1.1 (0.6, 1.9), p = 0.75 | 1.5 (0.3, 7.5), p = 0.67 |
Bed nets are a good way to prevent malaria | 1.5 (0.6, 3.5), p = 0.34 | 0.8 (0.3, 2.2), p = 0.67 |
Householder believes bed nets bought are better than free | 0.9 (0.7, 1.4), p = 0.54 |
0.5 (0.3, 1.0), p = 0.04
|
Attitudes towards bed net access | ||
Same chance of obtaining a bed net | 0.9 (0.7, 1.6), p = 0.74 | 1.2 (0.8, 1.8), p = 0.33 |
Bed net is easy to get | 1.2 (0.9, 1.7), p = 0.13 |
1.8 (1.3, 2.5), p = 0.0009
|
Could not afford a bed net if not free |
0.7 (0.5, 0.8), p = 0.001
|
1.9 (1.3, 2.8), p = 0.0005
|
Use of other prevention methods | ||
House has indoor residual spray | 1.1 (0.9, 1.4), p = 0.32 |
1.8 (1.4, 2.3), p < 0.0001
|
Factors associated with not using an available bed net
Characteristic | Crude OR (95 % CI), p = p value | Adjusteda OR (95 % CI), p = p value |
---|---|---|
Demographics | ||
Site (lowland = reference) |
1.8 (1.2, 2.8), p = 0.004
| |
Children under 5 in household | 0.8 (0.5, 1.1), p = 0.17 | |
Pregnant woman in household | 0.7 (0.3, 1.4), p = 0.29 | |
Female household head education level | ||
No school | 1 | |
Primary | 1.9 (0.7, 4.9), p = 0.18 | |
Secondary | 2.4 (0.9, 6.3), p = 0.07 | |
More than secondary | 1.4 (0.4, 4.5), p = 0.58 | |
Durable good ownership | ||
Radio | 0.7 (0.4, 1.1), p = 0.10 |
0.5 (0.3, 0.9), p = 0.01
|
Stove | 1.1 (0.6, 2.1), p = 0.71 | 0.8 (0.4, 1.6), p = 0.48 |
TV |
1.7 (1.1, 2.6), p = 0.009
| 1.7 (0.9, 3.4), p = 0.11 |
Indoor lighting | 0.6 (0.3, 1.5), p = 0.28 | 0.5 (0.2, 1.2), p = 0.11 |
Bike | 0.8 (0.5, 1.2), p = 0.24 | 0.7 (0.4, 1.2), p = 0.22 |
Sofa set |
1.5 (1.0, 2.3), p = 0.04
| 1.5 (0.8, 2.9), p = 0.26 |
Bed set | 1.4 (0.7, 2.7), p = 0.34 | 1.5 (0.7, 3.1), p = 0.28 |
Wealth group | ||
Very low | 1 | |
Low | (0.7, 2.6), p = 0.39 | |
Medium | 1.1 (0.6, 2.0), p = 0.64 | |
High | 1.6 (1.0, 2.7), p = 0.06 | |
Basic malaria knowledge | ||
Malaria transmitted by mosquitoes | Undefined | Undefined |
Fever a symptom of malaria | 0.8 (0.1, 6.1), p = 0.82 | 1.0 (0.1, 8.0), p = 0.98 |
Malaria prevented by bed nets | 0.4 (0.1, 3.0), p = 0.38 | 2.4 (0.3, 21.8), p = 0.43 |
Attitudes about malaria | ||
Family at risk of malaria | 1.7 (0.4, 7.2), p = 0.45 | 1.3 (0.3, 5.7), p = 0.71 |
Malaria is serious | 0.8 (0.4, 1.9), p = 0.67 | 0.9 (0.4, 2.0), p = 0.78 |
Children are more at risk than adults |
0.4 (0.2, 0.7), p < 0.001
|
0.4 (0.2, 0.6), p < 0.001
|
People in my community concerned about malaria | 1.2 (0.4, 3.9), p = 0.77 | 0.9 (0.3, 3.0), p = 0.82 |
Malaria history | ||
Known someone who died of malaria | 1.1 (0.8, 1.4), p = 0.52 | 0.8 (0.5, 1.2), p = 0.19 |
Known someone with severe complications of malaria |
1.4 (1.1, 1.9), p = 0.007
|
1.4 (1.0, 1.8), p = 0.02
|
Attitude towards bed nets as a prevention strategy | ||
Community believes bed nets are good way to prevent malaria |
0.3 (0.1, 0.6), p = 0.002
|
0.3 (0.1, 0.7), p = 0.008
|
Community rather buy other things than bed net | 1.5 (0.9, 2.5), p = 0.09 | 1.3 (0.8, 2.2), p = 0.32 |
Community thinks bed nets purchased better than free | 1.4 (0.9, 2.4), p = 0.13 | 1.4 (0.8, 2.3), p = 0.20 |
Household believes bed net is beneficial | 0.4 (0.2, 1.1), p = 0.08 | 0.6 (0.2, 1.7), p = 0.35 |
Bed nets are a good way to prevent malaria | 0.6 (0.3, 1.3), p = 0.22 | 0.8 (0.4, 1.8), p = 0.67 |
Household believes bed nets bought are better than free |
1.8 (1.1, 3.1), p = 0.02
|
1.6 (1.0, 2.5), p = 0.05
|
Attitudes towards bed net access | ||
Same chance of obtaining a bed net | 0.8 (0.4, 1.4), p = 0.41 | 0.8 (0.4, 1.4), p = 0.41 |
Bed net is easy to get |
2.1 (1.4, 3.2) 0.001
|
2.4 (1.6, 3.7), p < 0.001
|
Afford a bed net if not free |
1.7 (1.1, 2.7) 0.02
|
1.6 (1.0, 2.6), p = 0.03
|
Attitudes towards bed net use | ||
People in community only use during rainy season |
3.2 (1.9, 5.3), p < 0.001
|
2.8 (1.6, 4.8), p < 0.001
|
Householder only uses during rainy season |
2.1 (1.0, 4.1), p = 0.04
| 1.7 (0.8, 3.5), p = 0.16 |
No use using a net, I will get malaria anyway |
3.0 (1.6, 5.4), p < 0.001
|
2.3 (1.2, 4.3), p = 0.01
|
Using malaria drugs is easier than using bed net |
2.5 (1.5, 4.0), p < 0.001
|
2.2 (1.3, 3.7), p = 0.002
|
Using a bed net is difficult |
2.6 (1.5, 4.7), p = 0.001
|
2.2 (1.2, 4.0), p = 0.01
|
Other control measures taken | ||
Household received indoor residual spray | 0.7 (0.5, 1.1), p = 0.14 | 0.9 (0.6, 1.3), p = 0.59 |
Bed net characteristics
Bed net factor | Highlands (n = 976 bed nets) (%) | Lowlands (n = 827 bed nets) (%) |
---|---|---|
Age of bed net | ||
<1 year | 18 | 39 |
1–2 years | 52 | 51 |
3–4 years | 21 | 4 |
5–10 years | 8 | 5 |
10 + years | 1 | 2 |
Where bed net was obtained | ||
Free at clinic | 65 | 46 |
Free elsewhere including mass distribution | 8 | 36 |
Bought at market | 26 | 16 |
Bought from someone who obtained it for free | 1 | 2 |
Other | 0.4 | 0.2 |
Was bed net treated | ||
Yes | 85 | 73 |
No | 10 | 26 |
Unsure | 5 | 1 |