Abstract
BackgroundInsecticide-treated bed nets (ITNs) have been shown to reduce morbidity and mortality due to malaria in sub-Saharan Africa. Strategies using incentives to increase ITN use could be more efficient than traditional distribution campaigns. To date, behavioural incentives have been studied mostly in developed countries. No study has yet looked at the effect of incentives on the use of ITNs. Reported here are the results of a cluster randomized controlled trial testing household-level incentives for ITN use following a free ITN distribution campaign in Madagascar.MethodsThe study took place from July 2007 until February 2008. Twenty-one villages were randomized to either intervention or control clusters. Households in both clusters received a coupon redeemable for one ITN. After one month, intervention households received a bonus for ITN use, determined by visual confirmation of a mounted ITN. Data were collected at baseline, one month and six months. Both unadjusted and adjusted results, using cluster specific methods, are presented.ResultsAt baseline, 8.5% of households owned an ITN and 6% were observed to have a net mounted over a bed in the household. At one month, there were no differences in ownership between the intervention and control groups (99.5% vs. 99.4%), but net use was substantially higher in the intervention group (99% vs. 78%), with an adjusted risk ratio of 1.24 (95% CI: 1.10 to 1.40; p < 0.001). After six months, net ownership had decreased in the intervention compared to the control group (96.7% vs. 99.7%), with an adjusted risk ratio of 0.97 (p < 0.01). There was no difference between the groups in terms of ITN use at six months; however, intervention households were more likely to use a net that they owned (96% vs. 90%; p < 0.001).ConclusionsHousehold-level incentives have the potential to significantly increase the use of ITNs in target households in the immediate-term, but, over time, the use of ITNs is similar to households that did not receive incentives. Providing incentives for behaviour change is a promising tool that can complement traditional ITN distribution programmes and improve the effectiveness of ITN programmes in protecting vulnerable populations, especially in the short-term.
Highlights
Insecticide-treated bed nets (ITNs) have been shown to reduce morbidity and mortality due to malaria in sub-Saharan Africa
Reports of misuse of subsidized nets complicate the efforts of government and non-governmental organization (NGO) malaria prevention programmes seeking to promote ITN coverage and use in poor countries[7,8]
Various studies have demonstrated that providing nets for free is important to overcome the cost barriers associated with obtaining an ITN [9,10], but mere provision of free ITNs may not be enough to provide coverage for the required 80% of households that the WHO has indicated is necessary to provide community-wide "mass" protection from malaria[11,12,13]
Summary
Insecticide-treated bed nets (ITNs) have been shown to reduce morbidity and mortality due to malaria in sub-Saharan Africa. Insecticide-treated bed nets (ITNs) have been demonstrated to be of significant value in reducing morbidity and mortality due to malaria in sub-Saharan Africa[1,2]. Despite their accepted effectiveness, there remain barriers to the use of ITNs in vulnerable households, including both supply- and demand-side constraints, which make rapid scale-up of ITN coverage difficult to achieve. In recent years have performance-based incentives been more widely applied to the promotion of behaviours related to health problems in developing countries[16], such as childhood immunizations[17], nutrition[18], maternal care[19] and tuberculosis detection and treatment[20]
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