Background
The WHO’s Global Malaria Programme (GMP) recommends universal coverage with long-lasting insecticidal nets (LLINs) for all populations at risk of malaria in areas targeted for prevention and control [
1]. Coupled with increased distribution capacity and decreasing cost, global access to LLINs has increased by more than 50% in the past decade [
2], with 60% of the population in sub-Saharan Africa [95% CI 57–64%] now having access to ITNs in their household [
3]. In the past 2 years more ITNs were delivered in this region—189 million in 2014 and 178 million in 2015—than in any prior years [
3]. LLINs continue to be regarded as the most effective control measure against malaria [
1‐
4]. Nets treated with insecticides are more effective in reducing mortality and morbidity when compared to sleeping under no net or untreated nets [
4‐
7]. LLINs are cost-effective in reducing transmission, amounting in 2013 to an estimated $2.5 billion savings in malaria treatment costs [
2,
8,
9]. In sub-Saharan Africa, LLIN use contributed the largest savings to malaria case management costs (68%) between 2001 and 2014 [
10].
LLINs however, do not last forever. While they are understood to have a significantly longer protective effect compared to conventional, untreated or manually treated nets, their durability and level of insecticide deteriorates with time, use and maintenance. Long-lasting insecticidal nets, as recommended for public health use by the World Health Organization Pesticide Evaluation Scheme (WHOPES), have a manufacturer recommended lifespan of 3–5 years [
11,
12] compared to conventional nets which require annual retreatment [
1]. Despite this extended lifespan, LLINs require timely replacement for continued effectiveness in malaria prevention.
With millions of insecticide treated nets (ITNs) and LLINs already distributed, and knowing that these nets require replacement every 3 years [
3], a dilemma emerges from the potential environmental effect of the growing mass of discarded LLINs. The amount of polymer in one LLIN is equivalent to approximately 40–50 plastic bags or roughly 500 g of plastic [
13,
14]. The global distribution of over 659 million bed nets by 2015 [
15] therefore translates into a potential waste stream of over 216,000 metric tons of homogeneous polymer. An additional concern is that up to 30–80% of the full beginning-of-life dose of pesticide may remain in impregnated nets that are up to 7 years old [
13]. While insecticide-treated plastics can be incinerated safely in high-temperature furnaces, suitable facilities are lacking in most countries. Burial away from water sources and preferably in non-permeable soil is an appropriate disposal method for net bags and old LLINs in the absence of a suitable high-temperature incinerator, though such disposal practices are not commonly adhered to in most malaria-endemic regions [
16].
Responding to this environmental concern, the UNEP and WHO
Strategic Approach to International Chemicals Management (SAICM) Quick Start Programme Trust Fund conducted a pilot project in 2010–2011 in Madagascar, Kenya and Tanzania to identify and assess the feasibility of environmentally-sound and cost-effective options for the collection, recycling and disposal of expired LLINs [
17]. In all country sites, a social science study was carried out to provide exploratory data on local socio-cultural factors that might prove decisive for the effective management of used LLINs and related consequences for uptake and net use. This article presents findings from the qualitative study carried out in four districts in Madagascar, with the objective to provide preliminary data on the influence of socio-cultural and ethical factors on LLIN coverage and use in the community, and the implication of these factors for future net collection activities.
Methods
Study design
Ethnographic methods, representing an emergent theory design, were employed to assess the LLIN life cycle, alternative net uses and other socio-cultural issues related to the collection, disposal and recycling of nets at community level. The anthropological study was ancillary to the USAID-Deliver recycling campaign carried out in Betioky, Ampanihy, Beloha, Taolagnaro, Tsihombe, and Ambovombe districts to assess the viability of collecting and recycling LLINs. A total of 22,559 nets were collected [
13]. Having undergone collection campaigns, the Madagascar setting presented a unique opportunity to explore barriers, enabling factors to collection of nets and related implications of these campaigns in the community.
Study site and population
The study employed a theoretical, non-random cluster sampling method within which communities were selected based on the criteria required to address the study objectives (Table
1). Four districts were purposefully selected: Betioky, Tsihombe, Ambanja, and Fenerive Est. Criteria for inclusion were collection campaign participation and success rates, district size, district geography and climate, epidemiological indicators, and accessibility to researchers. Betioky and Tsihombe were selected because of their inclusion in the USAID-Deliver recycling campaign and because of the wide variation in collection success rates (61 and 15% respectively), providing a strong basis for inter-district comparison. Ambanja and Fenerive Est were outside the USAID-Deliver programme. Locations within the districts were theoretically selected (Table
2).
Table 1
Study objectives by factor
Net coverage | To evaluate whether, in real life conditions, the presence of the old nets in the household is likely to maintain, increase or decrease general net coverage and use of LLINS |
Alternative/secondary net use | To assess under what conditions LLINs are no longer used for sleeping |
To identify alternative uses for bed nets which are no longer used for sleeping |
To inform the decision, based on observed socio-cultural and ethical activities, of whether or not alternative net uses should be discouraged or encouraged for increased malaria prevention |
LLIN distribution effectivity | To assess the factors related to continuation or cessation of using old ITN/LLINs for sleeping when newer nets are introduced in the household (i.e. do pregnant women and children use new nets or continue to use old nets while saving new nets for future use) |
Recycling practices and perceptions | To assess community acceptability of returning bed nets which are no longer used for sleeping during collection campaigns |
To explore general community perceptions about reusing, recycling, energy recovery, replacing and disposing of LLINs |
Perceived health risks from recycled LLINs | To assess communities’ perceived risk of using LLINs after recycling campaigns and related IEC campaigns attributed to the “toxicity” or “harmfulness” of LLINs |
To gather preliminary data on any possible concern related to the future implementation and corresponding health risks of LLIN life-cycle management |
Net type | To describe in detail the life cycle of varying types and make of bed nets in communities |
To assess community practices of LLIN use, maintenance and disposal in relation to net type and characteristics, both for nets currently in use and those newly distributed |
Net waste | To evaluate what socio-cultural and physical characteristics define a net as “expired” or “waste” (i.e. no longer used for any purposes) |
To identify local communities’ current methods of LLIN disposal of nets which are no longer used for any purposes |
Table 2
Characteristics and demography of study districts
Population | 194,562 | 104,369 | 180,446 | 292,219 |
Ethnic group (predominant) | Mahafaly | Antandroy | Antakarana; Sakalava | Betsimisaraka |
LLIN collection through USAID-Deliver (%) | 61 | 15 | None collected | None collected |
Municipalities | 27 | 13 | 23 | 12 |
Fokontany | 342 | 77 | 187 | 150 |
Geography | South-west | South | Northwest | East seaside area |
Sub-desert | Diana region |
Seaside area | East seaside area |
Topography |
Latitude | 23° 38 south | 25° 19 south | 13.68° south | 17° 22 south |
Longitude | 44° 55 east | 45° 29 east | 48.45° east | 49° 25 east |
Malaria transmission seasonality (facies) 2010 | Sub-desert | Sub-desert | Equatorial | Equatorial |
Occasional | Occasional | January–June | January–June |
Sporadic transmission | Sporadic transmission | Long-lasting transmission | Long-lasting transmission |
Malaria prevalence (2010) (%) | 1.30 | 3.74 | 12.04 | 11.33 |
Accessibility | Difficult | Difficult | Difficult | Highly accessible |
Data collection
Three qualitative data techniques were triangulated: formal and informal interviewing, focus group discussions (FGD), and direct observation. Information collected through informal discussions was used to guide participant selection for formal interviews and focus group discussions. Participant observation was used to compare interview statements with directly observed actions and was informed by an adaptive observation guide.
Interviews
Informants were selected based on gender, age, religion, ethnicity, locality, socio-economic status, net possession, net use, net preference, and opinions on net recycling. Formal interviews were conducted at both the household (community) and authoritative level. Authorities selected for formal interviews were expected to be involved in local health services or health surveillance.
Focus group discussions
Focus group discussions (FGD) have been proven as a critical tool for allowing participants to recall and express ideas that might otherwise not have emerged when alone [
18] and serve to provide supplementary information to individual in-depth interviews [
19]. Focus group discussions were held in groups of 3–10 people and followed an adaptive discussion guide. Each FGD sought to address only a select number of the total study objectives. Participants were recruited through matching of socio-demographic criteria to the study objective under discussion in the given group. Natural group discussions, defined as discussions with “persons who know each other already” [
20], were held with key malaria stakeholders who were involved in policy decisions surrounding LLIN use and recycling at the local level, and with selected community members.
Participant observation
The observation of people’s behaviour in their natural setting is a fundamental and often neglected part of qualitative research. It enables comparison of people’s ideas and stated behaviour with their actual behaviour. Participant observation was conducted within and outside district households in order to contrast people’s stated behaviour in interviews and FGDs with their daily actions. All investigators relied on an observation guide to track and record observations.
Sampling
After identifying district locations, respondents were theoretically selected (i.e. based on emergent results). Key informants were characterized under “authority” or “community” status (Additional file
1: Table 3). This breakdown served to guide a varied distribution of respondents from different standings in the community and to better inform respondent experience with net usage and distribution. All collected data were recorded after gaining participants’ verbal consent.
Analysis
Data analysis was a continuous, flexible and iterative process concurrent to data collection. All interviews, focus groups, and informal discussions were held in Malagasy, electronically recorded, transcribed and translated into French. Data was analysed in NVivo 10 developed by QSR international. A record of the most relevant informal conversations and important observations in the field were included in the database until saturation of results was achieved. Discussion between investigators was recorded and also included in the database. Intermittent data analysis in NVivo was conducted after data collection was complete in each district and cumulatively at the end of the study.
Concept definitions
Alternative net use is defined as the use of a net for another purpose than sleeping even when in good condition for sleeping. Secondary net use is used for a net that is no longer acceptable for sleeping and is re-purposed for other domestic and economic uses. Waste: a (piece of) used net that cannot be useful for sleeping, nor any alternative or secondary purposes. Fokontany: the smallest administrative division in Madagascar.
Ethical considerations
The study was reviewed by WHO and received a waiver from the Ministry of Health ethics committee in Madagascar. All fieldwork followed the code of ethics of the American Anthropological Association (AAA) [
21]. Following the AAA’s 1986 Statement on ethics for principles of professional responsibility, all interviewees were informed before the start of the interview about project goals, question topic, their right to refuse or stop an interview at any point, their right to withdraw any information during or after the interview, and the intended use of the results for scientific publications and reporting. Oral consent was preferred, since interviewees were not at risk of physical or psychological harm and because written consent during conversation presents a potential reason for mistrust. All data was anonymized and labelled by study code to ensure participant anonymity.
Discussion
Collecting LLINs at their end of life cycle has the possibility to reduce net coverage and use in the community if social and cultural factors are not well understood and integrated into campaigns. In Madagascar, preference for certain net characteristics and reluctance to exchange nets due to remaining economic value placed on nets for their primary, secondary and alternative use were further deterrents to relinquishing nets for collection. The influence of LLIN preference on optimal net use and coverage has been demonstrated elsewhere. In the Solomon Islands community members exhibited a preference for polyester nets, citing large mesh size and inadequate bed coverage of polyethylene nets as reasons for intermittent or no net use [
22]. Research of LLIN use in Peru similarly found mesh size and transparency of polyethylene nets to lead to lower net use compared to traditional opaque nets [
23]. Net preference, as based on net make, size, and colour, has been found to influence LLIN total coverage in multiple other settings in sub-Saharan Africa [
24‐
26]. Programmes seeking to increase net coverage and appropriate net use must account for LLIN preference of the local community.
The economic value placed on nets, for both sleeping and alternative uses, along with the sense of individual net ownership, raises the question whether it is feasible to recycle LLINs at their end of life considering they are being used far longer and for purposes other than sleeping. Collecting nets at the stage of perceived “waste” conversely—when they are no longer used for any alternative or secondary purpose and no longer hold economic value would constitute a more realistic and acceptable approach at the local level.
The strategy by which expired LLINs are collected from communities influences how likely members are to relinquish worn nets and maintain total net coverage with new LLINs. For a collection strategy to be effective, early involvement from both local authority and community members is necessary. Informing district participants of collection intent and methods prior to upcoming distribution campaigns can serve to limit feelings of betrayal or infringement on net ownership when nets are collected and exchanged for new ones. In this setting, door-to-door net collection represents the most effective collection strategy, evidenced by the high rate of nets collected through this method in the Betioky district and by the stated preference for this strategy across all study districts. As worn and dirty nets can raise issues of social stigmatization and embarrassment, door-to-door campaigns can serve to avoid feelings of shame by leaving collection activities in the private sphere instead of public arenas. The ability of community members to retain and verbalize messages they learned during collection campaigns around proper net use, maintenance and handling indicates that educational communication efforts could be effective in presenting applications for alternative net uses to communities. Because discrepancies were observed between verbal discussions of net usage and actual daily use practices such as for fishing and food storage, additional measures, beyond education and communication campaigns, must be incorporated in any net replacement/distribution campaigns.
For any LLIN collection strategy to be effective in removing end-of-life nets from the community without reducing coverage, it must (i) ensure users are confident that they will receive a new net at the time of collection and (ii) that the collection strategy has been previously explained and agreed upon within the community to overcome barriers associated with relinquishing privately owned items. Taking into account these provisions at the local level, the effectiveness of any net collection strategy could raise ethical concerns if users are not informed that relinquishing LLINs is voluntary and cannot be required by authority leaders or governing entities.
An effective collection strategy must also consider the timing of when new LLINs are distributed in relation to when worn nets are collected. New LLINs must be distributed at the same time worn nets are collected to prevent gaps in coverage. While net preference may hinder a community’s willingness to relinquish nets for fear of receiving an “inferior” net type, it is not possible for countries to procure, or for donors to provide, nets based on this preference [
27,
28], due largely to cost-effectiveness of distribution and supply chain limitations. Limitations on a country’s ability to meet the net preferences of its population increase the importance of efficient net replacement strategy and of educating communities on appropriate of net use.
It is possible that the collection of LLINs that are being used for any purpose might under certain conditions lead to lower LLIN coverage. While coverage rates are shown to be higher for vulnerable populations [
29], net possession does not necessarily indicate utilization [
30], as alternative or misuse of LLINs continue to be cited as one of the reasons why nets are not used for sleeping [
22,
31‐
33]. It is possible that low social acceptability of worn nets or of non-preferred new nets leads to alternative uses [
23], thereby reducing coverage. If residual insecticide is significant in expired LLINs still in secondary use, the health impact may be significant based on the type of repurposing. Expired LLINs which are employed for alternative vector control uses, such as using the net as eves covers, doors or bath curtain [
17,
34] may be worthwhile to advocate as a malaria prevention strategy. However, if expired LLINs are being used for non-vector control purposes, such as fishing and in crop protection, [
25,
26] potential health impact of residual insecticides needs to be understood in greater depth to dissuade potentially harmful practices. There is a need to further document such alternative uses and to clarify the extent to which new or expired nets are being put to secondary use.
Study limitations
The study was limited in scope to a qualitative design and would have benefitted from an additional quantitative strand to quantify assessed factors and their relation to coverage and use of LLINs. The depth of information gathered through formal interviews and from focus groups was at times limited by social desirability bias manifesting in participants’ fears to discuss the use of nets for alternative or secondary purposes as this was often considered to be socially unacceptable or even be breaking the law.
Authors’ contributions
AR, RR, SH, and KPG made substantial contributions to study conception and design, data collection, management and analysis. MWB was responsible for drafting the manuscript and revising it critically for important intellectual content including updating the final version based on reviewer comments. In addition to the aforementioned authors, HR, MDR, AR, AF, and JMR have given final approval of the version to be published and have agreed to be accountable for all aspects of the work. All authors ensure that questions related to the accuracy or integrity of any part of the work can be appropriately investigated and resolved. All authors read and approved the final manuscript.