Predictors of Mosquito Net Use in Ghana

This 22-page study examines factors associated with the use of insecticide treated nets for the prevention of malaria in Ghana. During the past decade, the malaria control community has been successful in dramatically increasing the number of households that own mosquito nets. However, as many as half of nets already in households go unused. The study found that nets that were purchased and are blue in colour were more likely to be used; it also suggests a need to sensitise people that malaria is caused only by night-biting mosquitoes and that burning repellent coils is not a substitute for using a net.

Data for the study was collected through the Academy for Educational Development's (AED, now FHI 360) NetMark Project, a ten-year (1999-2009) United States Agency for International Development funded project, designed to reduce the burden of malaria in sub-Saharan Africa by increasing the commercial supply of and public demand for insecticide treated nets. The survey included an enumeration of each net in the household and information about size, shape, colour, source, cost, treatment status (insecticide treated net (ITN), long-lasting insecticide treated net (LLIN), or not), and whether or not it had been slept under the prior night.

Nets were classified as free, purchased, or other. Purchased nets included those bought at subsidised prices, those bought with vouchers, and those bought at full commercial prices. A majority (64%) of nets owned had been acquired free of charge; 34% had been purchased; and 2% were acquired as a gift or through trade or barter. The study found that of nets owned, 59% reportedly had been used the prior night – i.e., had someone sleeping under them the night before the survey. Over 40% of nets in this sample had not been used the prior night – a large proportion that represents considerable loss of protection against malaria, especially since the survey took place during the rainy season. About 21% of nets owned were still in the sealed package, thus had never been used.

The data showed that old nets were less likely to be used than newer ones and that a net that is less than a year old is far more likely to be used than a net that is four or more years old. The mother/guardian’s educational level and knowledge were found to be associated with a net being used as well. This analysis found that the odds of a net being used in a household where the mother/guardian had at least 10 years of education were 2.32 compared to a net owned by a respondent with no education. The odds of a net being used belonging to a mother/guardian who knew that mosquitoes transmit malaria was 1.4 in comparison to a net belonging to a mother who did not know the transmission vector. In this study, 63% of nets owned were white nets, but light blue nets were more likely to be used than white nets. Possibly light blue is preferred to white because colour does not show dirt as readily as white, or because a coloured net is considered decorative. Although colour of net was statistically significant, shape and size of net, as well as brand, were not.

The odds of a net from a household that had used coils for mosquito protection in the prior year being used were lower than for a net from a household that had not used coils, suggesting that households use coils to substitute for net use. The survey from which the data were drawn found that coils were used across the socio-economic spectrum among 58% of households, and that about 43% of those households used them virtually daily. The study suggests that in Ghana it may be important to dispel the idea that nets are not needed if you burn coils.

The study also found that a net that was purchased was much more likely to be used than one acquired free of charge. An item that is purchased is one that is wanted or needed. If a decision is made to purchase a net, it implies that the benefits of having, and using, a net are recognised, which is not necessarily the case if the net has been given for free. Further, if a net is purchased, the desired size and colour can be selected. The finding suggests that it is important to devise strategies for supporting the commercial market for nets while making nets available through mass distribution.

In conclusion, the results of this study suggest that net use would increase in Ghana if:

• coloured nets were made available in mass distributions as well as in the commercial market;
• programmes emphasise that malaria is caused only by night-biting mosquitoes, and that nets protect against mosquitoes better than coils and need to be used even if coils are burning;
• if donated nets are replaced more frequently so that households have nets that are in good condition; and
• there were support for the commercial market so that those who can afford to purchase a net and want to choose their own nets can do so.