Ownership and use of long-lasting insecticidal nets three months after a mass distribution campaign in Uganda, 2021
Authors: Kwiringira Andrew , Nanziri Carol , Nsubuga Edirisa Juniour , Migamba Stella Martha , Ntono Vivian , Atuhaire Immaculate , Ahirirwe Sherry Rita , Asio Alice , Senyange Shaban , Nakamya Petranilla , Masanja Veronicah , Elayeete Sarah , Komakech Allan , Nansikombi Hildah T. , Mwine Patience , Nampeera Rose , Ndyabakira Alex , Okello Paul , Migisha Richard , Bulage Lilian , Kwesiga Benon , Kadobera Daniel , Rutazaana Damian , Harris Julie R. , Ario Alex R. 
Published: December 2022

Abstract
Background
Uganda conducted its third mass long-lasting insecticidal net (LLIN) distribution campaign in 2021. The target of the campaign was to ensure that 100% of households own at least one LLIN per two persons and to achieve 85% use of distributed LLINs. LLIN ownership, use and associated factors were assessed 3 months after the campaign.

Methods
A cross-sectional household survey was conducted in 14 districts from 13 to 30 April, 2021. Households were selected using multistage sampling. Each was asked about LLIN ownership, use, duration since received to the time of interview, and the presence of LLINs was visually verified. Outcomes were having at least one LLIN per two household members, and individual LLIN use. Modified Poisson regression was used to assess associations between exposures and outcomes.

Results
In total, 5529 households with 27,585 residents and 15,426 LLINs were included in the analysis. Overall, 95% of households owned ≥ 1 LLIN, 92% of the households owned ≥ 1 LLIN < 3 months old, 64% of households owned ≥ 1 LLIN per two persons in the household. Eighty-seven per cent could sleep under an LLIN if every LLIN in the household were used by two people, but only 69% slept under an LLIN the night before the survey. Factors associated with LLIN ownership included believing that LLINs are protective against malaria (aPR = 1.13; 95% CI  1.04–1.24). Reported use of mosquito repellents was negatively associated with ownership of LLINs (aPR = 0.96; 95% CI 0.95–0.98). The prevalence of LLIN use was 9% higher among persons who had LLINs 3–12 months old (aPR = 1.09; 95% CI  1.06–1.11) and 10% higher among those who had LLINs 13–24 months old (aPR = 1.10; 95% CI  1.06–1.14) than those who had LLINs < 3 months old. Of 3,859 LLINs identified in the households but not used for sleeping the previous night, 3250 (84%) were < 3 months old. Among these 3250, 41% were not used because owners were using old LLINs; 16% were not used because of lack of space for hanging them; 11% were not used because of fear of chemicals in the net; 5% were not used because of dislike of the smell of the nets; and, 27% were not used for other reasons.

Conclusion
The substantial difference between the population that had access to LLINs and the population that slept under LLINs indicates that the National Malaria Control Programme (NMCP) may need to focus on addressing the main drivers or barriers to LLIN use. NMCP and/or other stakeholders could consider designing and conducting targeted behaviour change communication during subsequent mass distribution of LLINs after the mass distribution campaign to counter misconceptions about new LLINs.