For years, the global malaria community was puzzled by what seemed to be low usage of life-saving insecticide-treated nets to prevent malaria among communities.
“There was a global perception that people were not using their insecticide-treated bed nets (ITNs),” recalls Gabrielle Hunter, who has led malaria programs at the Johns Hopkins Center for Communication Programs, “because research data showed that many people had not slept under a bed net the night before they were surveyed.”
Malaria programs made efforts to promote net use through social and behavior change activities, which had implementers and researchers wondering if these interventions were effective. “While this was a question that kept coming up, it just didn’t match with what we were seeing in communities where we worked” says Michael Toso, who has implemented malaria social and behavior change programs with CCP since 2014.
A key insight lay in the denominator. The net use data did not take into account how many people actually had access to bed nets in their homes. The issue, it turned out, wasn’t only about people’s behaviors. It was more that there were not enough bed nets available to cover everyone in each household. It was a net supply problem, not a social and behavior change problem, Hunter says. Thanks to advocacy by what was then the CCP-led NetWorks project and other global malaria partners, new methods to calculate net access and net use were developed and published in 2014 by Hannah Koenker, who led CCP’s malaria work at the time.
Thus, more than a decade ago, the ITN use-to-access ratio, a calculation created by CCP using data from the Demographic and Health Surveys (DHS), Malaria Indicator Surveys, and Multiple Indicator Cluster Surveys, became the ITN Net Use and Access report. Funded by USAID, it was distributed by email annually to help guide and tailor malaria control programs in dozens of countries by providing data on net use that took access into account.
Later, the CCP-led VectorWorks project transformed the static report into an interactive, user-friendly website of maps and charts, which it co-launched with the CCP-led Breakthrough ACTION project in 2019. Both projects were also funded by USAID.
Since then, the Breakthrough ACTION project has updated the go-to website, ITNuse.org, quarterly and disseminated it widely. The website provides both national and sub-national statistics as well as recommendations for malaria vector control and social and behavior change approaches based on the data. It is also useful to financial planning for malaria prevention programs.
Data going back to 2005 is included, showing trends over nearly two decades, and bed net use data is broken down by age, gender, wealth, and even season. Now, with the Breakthrough ACTION project ending, CCP has decided to continue making the investment necessary to keep this critical website accessible to the global malaria community. Despite major foreign aid cuts with devastating impact on USAID and its funding, CCP will ensure that, as a global health good, ITNuse.org will continue as a resource for anyone who wants to use it.
“The important thing is that we won’t lose this treasured tool for understanding net use behavior and for making evidence-based decisions for malaria programs,” Toso says.
With the defunding of foreign aid, a challenge now facing CCP is how to continue updating the site with new data, particularly after USAID’s termination of the DHS Program. The longstanding DHS Program gathered information on malaria and many other health indicators for more than 40 years. For many years, CCP was a partner to that project.
Bed net use is one of the most effective ways to prevent malaria, and high ITN use rates have long been a central goal of malaria programs in many parts of the world. Net distributions, mostly funded by donors such as USAID and the Global Fund to End AIDS, Tuberculosis, and Malaria, had first been prioritized for pregnant women and children under the age of five.
For the past 15 years, however, distribution campaigns shifted to universal access to nets, which typically base net quantities on population size, getting more nets into communities that need them.
The Democratic Republic of Congo, for example, has a high use-to-access ratio of 1.1, which means that, on average, for every household net owned, at least one family member is sleeping under a net. But when it comes to whether an individual slept under a net the night before, fewer than 50 percent of people in the DRC used one. Why? They don’t have enough nets to go around.
“In DRC, and many countries, the data on ITNuse.org show a clear pattern,” Toso says. “When households have enough nets for the whole family, any differences in the age or sex of who uses nets disappears.”
Hunter says the ITN use-to-access ratio has been a key to understanding the net use realities in countries impacted by malaria.
“What we have learned, by looking at net use in the context of access, is that a strong habit of net use has been built across malaria endemic countries. We can trust households to reasonably allocate nets,” she says. “Our job is just to get families enough nets, provide timely cues to use and care for their nets, and they’ll do what they need to do.”
If you would like to help support ITNuse.org and other global health goods that have experienced funding disruptions, please reach out ccpbd@jhu.edu.
