Traditional Nets Interfere with the Uptake of Long-Lasting Insecticidal Nets in the Peruvian Amazon: The Relevance of Net Preference for Achieving High Coverage and Use

Koen Peeters Grietens,Alex Tenorio,Annette Erhart,Hugo Rodriguez,Sarah Hoibak,Elizabeth Toomer,Joan Muela Ribera,Angel Rosas Aguirre,Dionicia Gamboa,Alejandro Llanos Cuentas,Veronica Soto,Umberto D'Alessandro,Philip Bejon

doi:10.1371/journal.pone.0050294

Abstract

BackgroundWhile coverage of long-lasting insecticide-treated nets (LLIN) has steadily increased, a growing number of studies report gaps between net ownership and use. We conducted a mixed-methods social science study assessing the importance of net preference and use after Olyset® LLINs were distributed through a mass campaign in rural communities surrounding Iquitos, the capital city of the Amazonian region of Peru.MethodsThe study was conducted in the catchment area of the Paujil and Cahuide Health Centres (San Juan district) between July 2007 and November 2008. During a first qualitative phase, participant observation and in-depth interviews collected information on key determinants for net preference and use. In a second quantitative phase, a survey among recently confirmed malaria patients evaluated the acceptability and use of both LLINs and traditional nets, and a case control study assessed the association between net preference/use and housing structure (open vs. closed houses).ResultsA total of 10 communities were selected for the anthropological fieldwork and 228 households participated in the quantitative studies. In the study area, bed nets are considered part of the housing structure and are therefore required to fulfil specific architectural and social functions, such as providing privacy and shelter, which the newly distributed Olyset® LLINs ultimately did not. The LLINs' failure to meet these criteria could mainly be attributed to their large mesh size, transparency and perceived ineffectiveness to protect against mosquitoes and other insects, resulting in 63.3% of households not using any of the distributed LLINs. Notably, LLIN usage was significantly lower in houses with no interior or exterior walls (35.2%) than in those with walls (73.8%) (OR = 5.2, 95CI [2.2; 12.3], p<0.001).ConclusionNet preference can interfere with optimal LLIN use. In order to improve the number of effective days of LLIN protection per dollar spent, appropriate quantitative and qualitative methods for collecting information on net preference should be developed before any LLIN procurement decision is made.

Highlights

The use of malaria preventive measures such as insecticide treated nets (ITNs) and Long-Lasting Insecticidal Nets (LLINs), by populations living in malaria endemic countries is a key aspect of the Global Malaria Action Plan’s established goals for 2015 [1] and is paramount to achieve the targets set by the World Health Organization (WHO) and the Roll Back Malaria Partnership [1
Patients Survey (Table 1) indicated that the majority of respondents reported that mosquitoes entered the OlysetH LLINs (93%, 95CI [87.9; 96.5]), that this phenomenon occurred since the beginning or after the first wash (89.1%, 95CI [85.0; 94.1]), and that mosquitoes did not die after entering the net (89.8%, 95CI [84.5; 94.7])
The presented research clearly shows that net preference can limit the optimal use of LLINs in some high-risk groups for malaria

Summary

Introduction

The use of malaria preventive measures such as insecticide treated nets (ITNs) and Long-Lasting Insecticidal Nets (LLINs), by populations living in malaria endemic countries is a key aspect of the Global Malaria Action Plan’s established goals for 2015 [1] and is paramount to achieve the targets set by the World Health Organization (WHO) and the Roll Back Malaria Partnership [1–2]. The impact of ITN use on reducing malaria mortality and morbidity has been repeatedly shown [3,4,5] and has lead to a steady increase of LLIN coverage in the last decade via mass distribution campaigns and keep-up strategies [1,2]. In terms of malaria prevention, the problem arises when users prefer locally produced or bought bed nets that are untreated with insecticide as they offer less protection against mosquito bites. Their use could interfere with the uptake of LLINs distributed by Malaria Control Programmes. While coverage of long-lasting insecticide-treated nets (LLIN) has steadily increased, a growing number of studies report gaps between net ownership and use. We conducted a mixed-methods social science study assessing the importance of net preference and use after OlysetH LLINs were distributed through a mass campaign in rural communities surrounding Iquitos, the capital city of the Amazonian region of Peru

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