Scope and Extent of Alternative Use of Bed Nets within the Arsi Zone in Ethiopia

This 14-page report of a C-Change study in the Arsi Zone of Ethiopia examined the scope and extent of bed net use for alternative purposes, drawing comparisons between communities reached and not reached by complementary C-Change social and behaviour change communication (SBCC) activities. The study noted higher alternative use of bed nets in comparison communities not reached by SBCC activities. In communities reached by C-Change's SBCC interventions, the study found higher bed net use for malaria prevention and a narrower gap between bed net ownership and bed net use. The types of alternative uses observed in both communities included use as bedding, curtains, side wall for outdoor toilets, cover for grain, and rope. The report offers recommendations for SBCC programmes that promote bed net use for malaria prevention and control.

According to the report, bed nets were available for observation in over 90% of the SBCC intervention and comparison households that reported owning them. In intervention communities, 96% of households reported owning one or more bed nets, and interviewers observed at least one bed net in 92% of households. In comparison communities, 99% of households reported ownership of at least one bed net, and interviewers observed at least one bed net in 96% of households. When bed nets reported to be owned were not available for observation, the most frequent reason given was that they were stored in a locked trunk within the house.

In intervention communities, 94% of households had at least one bed net that had been taken out of its original packaging. This initial step had been taken by 87% of comparison households. More intervention households had taken the additional step of hanging the bed net from a wall or ceiling so it could be slept under. At the time of the interview, 48% of intervention households with at least one bed net had a bed net hanging from a wall or ceiling. This was true of only 21% of the comparison households. The proportion of all households reporting that someone had slept under a bed net the previous night was 46% in intervention households and 19% in comparison households.

Where bed nets were observed, alternative use was higher among comparison households than among intervention households. Among comparison households, 56% used at least one whole or partial bed net for an alternative purpose, compared to 37% of households in intervention communities. Use of at least one whole bed net for an alternative purpose was observed in 48% of comparison households and in 13% of intervention households. The use of one or more partial bed nets for alternative purposes was observed in 5% of comparison households and 20% of intervention households.

Among households who used at least one bed net for any purpose, bed net use for alternative purposes was three times higher (70%) - within comparison communities than intervention communities, where 24% of households used bed nets for alternative purposes. Use of bed nets for malaria protection was observed in 63% of intervention households and among 26% of the comparison households. Use of whole or partial bed nets for both alternative and intended purposes was low in intervention households and rare in comparison households.

The report noted that different types of alternative uses observed can be categorised into two groups. In the first group are bed nets used in homes and compounds for functional or aesthetic purposes that provide marginal protection against malaria. Such uses include the use of bed nets as bed sheets, mattress covers, room partitions, and covers or side walls for outdoor toilets. In the second group are uses specific to the farming communities in this study. These uses do not provide protection against malaria, and include bed nets used to cover grain, make rope for ploughs, or create livestock stables.

The report concludes that alternative use of bed nets was higher in comparison communities, while bed net use for malaria prevention was higher in intervention communities. The lower alternative use and higher intended use of bed nets in intervention communities suggest a positive effect of the C-Change SBCC activities that accompanied LLIN distribution. The intervention appears to be having a positive effect on intended and alternative use of bed nets. Given this, it is recommended that ongoing malaria programmes with low to moderate alternative use refine existing communication strategies to better address barriers and facilitators for correct bed net use, increase intended use, and decrease non-use and alternative use. There does not appear to be a need to develop a new, separate communication strategy that focuses on reducing alternative use in cases where low to moderate levels of alternative use are observed. This might be warranted in situations where much higher levels of alternative use that hinder or prevent intended use are observed.