Lam et al. Malaria Journal 2014, 13:183
http://www.malariajournal.com/content/13/1/183
RESEARCH
Open Access
Decision-making on intra-household allocation of
bed nets in Uganda: do households prioritize the
most vulnerable members?
Yukyan Lam1, Steven A Harvey1*, April Monroe2, Denis Muhangi3, Dana Loll3, Asaph Turinde Kabali4
and Rachel Weber2
Abstract
Background: Access to insecticide-treated bed nets has increased substantially in recent years, but ownership and
use remain well below 100% in many malaria endemic areas. Understanding decision-making around net allocation
in households with too few nets is essential to ensuring protection of the most vulnerable. This study explores
household net allocation preferences and practices across four districts in Uganda.
Methods: Data collection consisted of eight focus group discussions, twelve in-depth interviews, and a structured
questionnaire to inventory 107 sleeping spaces in 28 households.
Results: In focus group discussions and in-depth interviews, participants almost unanimously stated that pregnant
women, infants, and young children should be prioritized when allocating nets. However, sleeping space surveys
reveal that heads of household sometimes receive priority over children less than five years of age when
households have too few nets to cover all members.
Conclusions: When asked directly, most net owners highlight the importance of allocating nets to the most
biologically vulnerable household members. This is consistent with malaria behaviour change and health education
messages. In actual allocation, however, factors other than biological vulnerability may influence who does and
does not receive a net.
Keywords: Malaria, Insecticide-treated bed nets (ITNs), Bed net allocation, Bed net access, Mosquito nets, Uganda,
Qualitative research, Net use patterns
Background
Ownership of insecticide-treated bed nets (ITNs) has increased greatly in recent years. In Uganda, the percentage of households owning at least one ITN grew from
16% to 60% between 2006 and 2011. Despite these gains,
only 45% of the country’s population had access to an
ITN in 2011 [1]. As defined by the Demographic and
Health Survey (DHS) and as used in this paper, ‘access’
refers to the percentage of the population living in
households with one ITN for every two people. Thus,
the gap derives both from households with no ITNs and
from those with too few ITNs to cover all household
* Correspondence: sharvey1@jhu.edu
1
Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street,
Baltimore, MD 21205, USA
Full list of author information is available at the end of the article
members. In fact, only 28% of households had at least
one ITN for every two people. Both peri-urban and rural
households owned an average of 1.3 ITNs, while their
average size was 3.8 and 5.1 persons, respectively [1].
Moreover, recent research by Killian et al. suggests
that current methodology significantly overestimates
bed net access [2]. The access problem is compounded
by the fact that ITNs – including long-lasting insecticidal nets (LLINs) – wear out at varying rates that depend on household environment, as well ask net use,
care, and repair [3-7]. At the same time, household poverty and dependence on global donor funds affect ability
to replace nets readily [8,9].
Pregnant women, infants, and young children are particularly vulnerable to malaria [10,11]. Studies in sub-Saharan
Africa have found that ITN use contributes to significant
© 2014 Lam et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Lam et al. Malaria Journal 2014, 13:183
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reductions in placental malaria, low birth weight, and
still-births, as well as reduced morbidity and mortality
among children under five [12,13]. Continuing net shortages make it critical to understand how households allocate
nets among their members and whether the most biologically vulnerable groups are protected.
There have been few studies on intra-household net
use patterns. Among the more recent research, two
population-based surveys concluded that households
with insufficient nets, or insufficient ITNs, to cover all
members give priority to pregnant women and children
under five [14-18]. The first, a multi-country study in
Ethiopia, Ghana, Mali, Nigeria, Senegal, and Zambia, used
survey data from 2000 to 2004 about households, their
members, and the occupants of each bed net owned [14].
In each country, data showed that children under five and
women of reproductive age, especially pregnant women,
were most likely to sleep under a net. Children between
five and 14 years of age and adult males were least likely.
However, sub-analysis by study site showed that some
areas had different net use patterns.
The second study, conducted in 2006, analysed data
from the Tanzania National Voucher Scheme, which offered pregnant women subsidies to purchase ITNs [16].
Surveys enumerated which household members slept
under each net the previous night and which slept without a net [16,19]. Researchers studied intra-household
“net equity” by determining who slept under treated versus untreated nets and who slept under nets with fewer
holes [16]. Results showed that infants were the group
most likely to sleep under an intact ITN. In households
with at least one untreated net, one ITN, and one infant
or young child, probability of ITN use decreased by age:
infants had the highest probability, followed by young
children and women of reproductive age, adult males and
older children, and finally older women.
A Ugandan study using 2000–2001 DHS data found
that children were much more likely to sleep under a bed
net if their mothers also used one [17]. Although the DHS
did not ask about the number of nets in the household or
whether children shared a sleeping space with their mother,
stratified statistical analyses strongly suggested that children
who slept under a bed net did so because they were sleeping in the same space as their mother [17]. Researchers
thus concluded that primary protection was not aimed
specifically at children themselves [17].
The present study used qualitative methods to examine
intra-household net allocation in four Ugandan districts.
It explored hypothetical versus actual allocation and
compared both to international guidelines that prioritize
pregnant women and children under five [20]. The generic
terms, “net” and “bed net,” are used rather than “ITN” or
“LLIN,” due to difficulty in conclusively determining net
type during household visits. Use of the terms, “ITN” and
Page 2 of 11
“LLIN,” imply explicit information on the type of net
being referenced.
Methods
This article presents data from the first two phases of a
three-phase study on the culture of ITN use in Uganda.
Phase 1, conducted early in the rainy season in March
2012, began with Nebbi and Luwero Districts in Uganda’s
Northern and Central Regions, respectively. In each
district the study team recruited six households: three
rural and three peri-urban. Study team members completed sleeping space questionnaires (SSQs) for every
sleeping space in each household and conducted an indepth interview (IDI) with one adult household member. The team also organized one rural and one peri-urban
focus group discussion (FGD) per district, with participants drawn from both participating and non-participating
households.
In phase 2, conducted during the dry season in January
2013, the team revisited the 12 households from Nebbi
and Luwero and updated sleeping space information by
administering new SSQs. They also enrolled two new
households in each district and completed SSQs and IDIs
for them. In addition, Ibanda and Kaberamaido Districts
were added in the Western and Eastern Regions, respectively, with six households recruited from each district.
IDIs were also conducted with these households. However,
as IDIs in phase 2 did not address net allocation, their
findings are not presented here. Two FGDs were conducted in each new district with participants belonging to
already recruited households or other households from
the same sub-counties (Figure 1).
Sampling
The four districts were purposively chosen to represent
Uganda’s four regions and to include districts where nets
had been distributed in the preceding three years. Within
each district, the district chairman or district health officer
helped select two communities, one from a peri-urban
and another from a rural sub-county. In each community,
village leaders assisted with purposively selecting households for SSQs and IDIs to ensure geographic representation and ownership of at least one bed net.
Within households, any adult member was eligible to
complete the SSQ. Most often, the participants sleeping
in a given sleeping space assisted with the SSQ for that
space. IDIs were conducted with the head of household
or his or her spouse when possible. An adult household
member not participating in the IDI was eligible to partake
in a FGD. Additional FGD participants were recruited
by convenience sampling from households owning at least
one bed net in the same village. Participants, generally the
head of household or spouse, were selected based on gender such that one all-male and one all-female FGD, each
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Page 3 of 11
Figure 1 Map of Uganda with study areas highlighted in green.
consisting of seven to ten participants, was conducted per
district. All IDIs and FDGs were audio recorded.
Interview and focus group themes
All FGDs and the phase 1 IDIs included the topics of
malaria prevention, use and care of bed nets, and household sleeping space allocation. They also included a participatory exercise designed to elicit factors that influence
intra-household allocation of sleeping spaces and bed nets.
In this exercise, moderators provided participants with
photographs of ten different individuals, separate photographs of four sleeping spaces, and three swatches of bed
net fabric. The subjects in the photographs included men,
women, boys, and girls ranging from infant to elderly.
Two of the pictured sleeping spaces consisted of beds with
spring mattresses and linens, another was a foam rubber
mattress placed on the floor, and the last was a thin straw
mat on the floor. One of the bed net swatches represented
a new net with no holes, another represented a slightly
used and discoloured net with a few small holes, and the
third a very worn and soiled net with several large holes
and tears (Figure 2). Materials used for the participatory
exercise (photographs and swatches) were the same between phases 1 and 2.
During the allocation exercise, the IDI or FGD participants were asked to assign the individuals to sleeping
spaces and bed nets. Since there were only three nets,
one of the participant’s tasks was to decide which
sleeping space would remain without a net. The moderator then asked the participant to explain the factors influencing his or her assignments. In the focus group
setting, after one volunteer presented his or her arrangement, the moderator invited discussion from other
group members. The moderator then invited two additional
participants to complete the exercise and suggest alternative arrangements. Each configuration was photographed.
Figure 2 Sleeping space arrangement recorded from Ibanda
peri-urban focus group.
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Sleeping space questionnaires
The study team completed SSQs for each sleeping space
in the selected households. A study team member asked
who had slept in each space the previous night, as well
as each occupant’s age, sex, marital and pregnancy status,
education level and relationship to the household head.
The questionnaire also elicited characteristics of any net
associated with the sleeping space, including how long it
had been used, how it was cared for, and whether it had
been repaired. Some of the questions, such as whether the
net appeared dirty, were verified by observation. However,
most of the care and repair questions, such as how often
the net was washed, were not.
Analysis
IDIs and FGDs were transcribed, translated into English,
and coded for key themes using ATLAS.ti [21]. A codebook
developed by two members of the research team included
codes relevant to the sleeping space exercise and to sleeping
space and net allocation more broadly. Stata® version 12
was used to generate descriptive statistics from the
sleeping space questionnaires [22]. Also using SSQ data,
sleeping space maps were manually constructed to analyse
sleeping arrangements at the household level.
Ethical review
Ethical approval for the research was secured from the
Johns Hopkins University Bloomberg School of Public
Health Institutional Review Board in Baltimore, Maryland,
and from the Joint Clinical Research Center and the
Uganda National Council for Science and Technology
Institutional Review Boards in Uganda.
Results
In phases 1 and 2, a total of eight focus groups were
conducted, one male and one female in each of the four
districts. Each group included seven to ten participants.
Phase 1 also incorporated 12 IDIs, six in Luwero and six
in Nebbi (Table 1). As noted earlier, phase 2 IDIs did not
address net allocation so their results are not reported
here. The sleeping space allocation exercise with photographs was carried out during FGDs in both phases and
Table 1 In-depth interviews and focus group discussions
by district
District
In-depth interviews
Focus groups (participants)
Male
Female
Total
Male
Female
Total
Ibanda
NA
NA
NA
1 (10)
1 (10)
2 (20)
Kaberamaido
NA
NA
NA
1 (10)
1 (10)
2 (20)
2
4
6
1 (9)
1 (7)
2 (16)
Luwero
Nebbi
2
4
6
1 (8)
1 (10)
2 (18)
Total
4
6
12
4 (37)
4 (37)
8 (74)
during IDIs in phase 1. SSQs were administered for a total
of 107 sleeping spaces in 28 households: six each in
Ibanda and Kaberamaido; eight each in Luwero and
Nebbi (Table 2). In each district, half of the households
were located in peri-urban areas, the other half in rural.
All 28 households owned and used at least one net
(Table 3). Eleven (39%) had nets associated with every
sleeping space, while 17 (61%) had one or more sleeping
spaces with no net. Hereafter this group is referred to as
the ‘17-household subsample with insufficient nets.’
Of the 107 total sleeping spaces, 68 (64%) had nets while
39 (36%) did not. Among the 68 with nets, 58 (85%) were
protected by a single net while nine had an extra, secondary net. Information about one space was ambiguous.
Two of the spaces with extras nets were located in households where some other sleeping space lacked a net. As
reported by respondents, the nets ranged in age from
one month to five years, with an average of 26 months.
Age information was missing for four nets.
Across the 28 households, there were 175 individuals
who slept in the household the previous night, yielding
an average of 6.25 members per household. Table 4 shows
ages for all but four of those 175 individuals. The 107
sleeping spaces yielded an average of 3.82 sleeping spaces
per household. Ten of these 107 spaces were unoccupied
the night prior to the survey. Excluding these ten, each
sleeping space averaged 1.8 occupants.
Hypothetical allocation: the sleeping space and net
allocation exercise
During in-depth interviews and focus group discussions,
participants generally agreed that pregnant women and
very young children should receive priority when allocating sleeping spaces and nets. In the hypothetical net allocation activity that used photographs, the pregnant
woman and the children meant to appear under five
years old were most often assigned a bed with a mattress
and the new net with no holes. Across all districts and
among participants of both genders, the baby was most
often assigned the best net, followed by the pregnant
woman (see, for example, the arrangement portrayed in
Figure 2). The old man was least likely to be assigned the
best net and often was assigned no net at all. On only a few
occasions did participants assign him the best net and
sleeping space. Opinions differed regarding the age at
which older adults might need additional protection.
There was also considerable variation in placement of
older children, whose assignments ranged from the
best net and sleeping space to the worst.
Participants gave multiple reasons for their allocation decisions. However, the justification given almost
universally for prioritization was biological vulnerability. For example, after assigning the pregnant woman,
baby, and youngest boy and girl to the best bed and
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Table 2 Sample of households and sleeping spaces, by district
District
Households
surveyed
Average no. of
members per household
No. of sleeping
spaces (% of total)
Average no. of
sleeping spaces
per household
Average no. of occupants
sleeping together in a single
space the prior night
Ibanda
6
7.0
28 (26.2%)
4.7
1.6
Luwero
8
5.5
30 (28.0%)
3.8
1.7
Kaberamaido
6
6.3
24 (22.4%)
4.0
1.6
Nebbi
8
6.4
25 (23.4%)
3.1
2.4
Total
28
6.3
107
3.8
1.8
newest net, one participant explained her arrangement
as follows:
how these other people suffer.” [Peri-urban FGD, Ibanda]
A female participant from Luwero echoed this logic:
“This woman is pregnant and these children are still
young, so they need proper care so that they are safe
from malaria. That’s why they have to use a treated
mosquito net, and again they have weaker blood
which makes it easier for them to get malaria.”
“I would not give first priority to the youth because
they are strong and their bodies can resist malaria…
I would only consider those that are more vulnerable
and leave those that are strong enough to fight.”
[Rural IDI, Luwero]
[Peri-urban FGD, Kaberamaido]
Many participants gave similar reasons – including
risk of losing the pregnancy – for prioritizing the same
individuals: “She is pregnant and if she is bitten by a
mosquito, malaria will also spread to the unborn baby,
and this may lead her to have a miscarriage.” [Rural
FGD, Ibanda] Others stated that pregnant women and
very young children would be unable to defend themselves
by chasing away or killing mosquitoes. Children over age
five were sometimes perceived as less vulnerable, but
still at risk: “They are also young but can resist malaria,
unlike the young one who is very vulnerable to malaria.”
[Rural FGD, Kaberamaido]
While participant opinions differed about net allocation
to older children and adults, those perceived as having
“good health” or “very strong immune system[s]” were not
assigned the best net. [Rural and peri-urban FGDs, Ibanda]
In explaining why the two oldest men in the photographs
were often left without a net, many participants voiced
the sentiment that “old people… cannot be disturbed by
malaria like other people. Even if they are bitten by mosquitoes and they fall sick, they do not get disturbed like
Table 3 Shortage of bed nets within households, by district
Total no.
of sleeping
spaces
Sleeping
spaces without
bed nets
Percentage of
sleeping spaces
without bed nets
Ibanda
28
16
Luwero
30
Kaberamaido
24
District
Beyond physical vulnerability, participants sometimes
based their decisions on personal characteristics they attributed to the pictured individuals. For example, some
participants denied the old man a net because they perceived him as someone who did not care about his
well-being, because he was old and no longer “useful,”
because he was more able to endure malaria, or because
he was seen as a drunkard and thus unable to feel the
mosquitoes. As one male participant explained:
“If the old man were a responsible person who cared
about taking care of himself, I would have given him a
good net. But from his appearance you can just see
that he is someone who drinks alcohol, an indication
that he does not want to take care of himself.”
[Rural FGD, Nebbi]
Alternatively, most members of another male focus
group in Ibanda agreed when one participant suggested
that the two oldest men pictured could do without a net
because “they can spend the whole night chatting, and when
Table 4 Household members sleeping in house on prior
night, by age group
Age group
Number of members
Percentage of total
Under 5 years old
39
22.3%
57.1%
5-14 year olds
58
33.1%
9
30.0%
15-49 years old
64
36.6%
5
20.8%
Over 49 years old
10
5.7%
Nebbi
25
9
36.0%
Unknown
Total
107
39
36.5%
Total
4
2.3%
175
100%
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they get disturbed they can decide to smoke and the smoke
can chase away the mosquitoes.” [Rural FGD, Ibanda]
Some participants noted that several of the individuals
in the photographs appeared nicely dressed or clean and
used this reason to assign them better sleeping spaces
and nets. Assuming the character of a well-dressed
young man in one photograph, a participant stated: “I
have just separated from my home. That is why my
things are still new. And again—me, I am like a youth,
I should not have dirt. I need to be clean.” [Rural FGD,
Kaberamaido]
Participants also invoked the assumed economic or
physical capacity of the pictured individuals. Adolescents,
young adults, and middle-aged adults were described as
able to care for nets, repair damaged nets, and as having
the energy to work and earn money for a new net. As one
male participant stated in assigning the net with many
holes to three such individuals, “if they are grown-up girls,
they should be able to see that the net is old, and they can
also buy a new net because they also know how to look for
money.” [Rural FGD, Kaberamaido]
Both responsibility and the burden associated with caring
for people of varying ages informed allocation decisions in
the hypothetical exercise, but participant interpretation of
these issues varied. As one female participant explained:
“For me, if I had an old man in my family and young
people, I would give a mosquito net first to the old man
because if he got sick, I would still be the one to suffer
with the medical bills. Treatment for old people is
normally more expensive than that of young ones and,
because of that, I would give the old man first priority.”
[Rural FGD, Luwero]
Another participant from the same FGD disagreed:
“I would mostly consider children below seven years to
sleep under the net because when children fall sick, it
is us parents who suffer treating them, and the degree
of severity of malaria among children is higher than
that of adults.”
A third cited the responsibility of caring for young
children and other household members:
“For me I would give myself the last opportunity to get
a net because being the owner of the household, I am
the one who is supposed to provide my dependents
with mosquito nets. If I gave myself the first priority, I
would appear as if I had forgotten the others and left
them to continue suffering [from mosquito bites]. It
would even look bad for me to get a net when the
other dependents have nothing.”
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Observed allocation: sleeping space questionnaires from
the 17-household subsample with insufficient nets
The net allocation observed in participating households
differed somewhat from that suggested by participants
in the hypothetical net allocation exercise. To explore
intra-household prioritization of nets, data are presented from the subsample of 17 households with insufficient nets to cover all sleeping spaces. A total of
122 individuals slept in these households on the night
prior to their participation in the study. Of these, 68
(56%) slept in a space with no net. When these inhabitants are stratified by age (Figure 3), 12 of 29 children
under five (41%) slept with no net, as did 33 of 42 children ages 5 to 14 (79%) and 20 of 48 adults ages 15
and older (42%). There was only one pregnant woman
in the subsample; she was reported to sleep with a net.
Two other pregnant women in the broader sample
lived in households with sufficient nets to cover all
sleeping spaces.
In the 17-household subsample, 14 heads of household
slept at home on the night prior to the SSQ. The identity
and whereabouts of three heads of household were unknown. Only two out of the 14 identified heads of
household (14%) slept in a space with no net, compared
to 18 of 34 adults (53%) who were not heads of household (Figure 3). Of the 12 heads of household in the
subsample who slept with a net, half did so while at least
one child under five in their household slept without
one. Figure 4A illustrates one such example. In most of
these cases, the household head either slept alone or
with older children or adults. In only one case did the
household head share his sleeping space with a child
under five. This does not necessarily imply that all children under five in those households slept unprotected.
For instance, in one peri-urban Luwero family, the head
of household and his wife slept together under one net,
a 1 year-old boy and 2 year old girl shared another, a
4 year old boy and 10 year-old girl shared a third, but a
4 year-old girl and 6 year-old boy slept without a net
(Figure 4B). However, there was no household in which
all children under five slept with a net while the head of
household was left without.
After describing how she and her infant, 4- and 6-year
old children sleep together on a papyrus mat on the
floor with no net while her husband sleeps on a bed
with a net and a mattress, a Nebbi IDI informant offered
the following explanation:
“We had in mind that the man, as the head of the
family, should be the one to get it first; [he] has to
sleep on the bed. If God provides more, then me and
the kids shall get later.”
[Rural IDI, Nebbi]
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Figure 3 Numbers and percentages of individuals whose sleeping space had a net or no net among the 17 households with
insufficient nets.
The informant added that the single bed had room for
only one person, making it impossible for her and her
children to sleep on it together. On the other hand, the
children were too young to sleep alone, so to be with
her the only option was to sleep on the floor. As for the
net, the informant reported,
“…that one is just because it is not possible to hang the
mosquito net on a papyrus mat, but the net can be
hung on the bed so it was appropriate for the
mosquito net to be on the bed.”
Household heads were not the only ones sometimes
prioritized over children under five in net allocation. In
four households, older children, teenagers, or adults who
were not the head of household slept with nets while at
least one child under five did not. Again, this did not necessarily imply that all children under five slept without
a net in those households.
Looking across districts, Ibanda was the district with
the most households experiencing net shortage; all six
households surveyed there lacked a net for at least one
sleeping space. It was also the district with the most
prioritization of family members other than children under
five in net allocation. There were four households where
children under five slept in spaces without nets while older
children, adolescents, and other adults (both heads and
non-heads of household) were allocated spaces with nets.
Discussion
Malaria control programmes have emphasized the importance of targeting vulnerable groups, including pregnant women and children under five, through health
communication and net distribution campaigns and other
malaria prevention interventions [11,20]. The early study
by Alaii et al. on intra-household net allocation in Kenya
found that heads of household were more likely than children under five to sleep under ITNs [15]. Most subsequent studies conclude the opposite: Households usually
prioritize biological vulnerability over other possible allocation criteria. For instance, after conducting IDIs with 19
adults in Zanzibar, Beer et al. found that young children
received priority for net use when households had insufficient nets to protect all members [23]. In their survey of
ITN use in over 2,400 Sri Lankan households, Fernando
et al. found that 75% and 90% of children under five slept
under a net during low and high malaria transmission season, respectively [24,25]. Baume and Marin’s five-country
population-based review of net use found “women of reproductive age and children under five… were most likely
to use the net; least likely were children of age five to
14 and adult males.” The authors concluded that net
campaigns should focus more on year-round use than
biological vulnerability [14].
Nevertheless, most studies also cite exceptions. In the
Fernando study [24], fewer than 50% of pregnant women
slept under a net. Baume and Marin found that 18% of
Senegalese households owning a single net allocated it
to someone other than a child under five or a pregnant
woman. They also found that net use among children under
five and pregnant women declined in Nigeria between 2000
and 2004, along with an overall decline in net use.
The results of this study are similarly equivocal, and
suggest a difference between social norms and observed
behaviours. Participants in the hypothetical allocation exercise made decisions mostly in line with program priorities.
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Page 8 of 11
Figure 4 Schematic diagram of sleeping arrangements observed in two households.
In assigning three nets across four sleeping spaces and ten
individuals, the great majority prioritized the pregnant
woman, the baby, and the children they perceived to be
under five. The pregnant woman and baby almost always
received the new net, while the slightly used net with a few
holes tended to go to other young children. Overall, these
participants seemed to understand – and at least in theory
accept – the importance of protecting household members
at greatest biological risk. As one female participant
explained:
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“When they came to distribute nets, priority was being
given to pregnant women and children under five…
Young children are highly vulnerable to malaria when
they are bitten by mosquitoes, a case that is not the
same like the old.”
[Peri-urban FGD, Ibanda]
Some participants used allocation criteria unrelated to
physical vulnerability that nonetheless aligned with
program priorities. For instance, while young and middleaged adults are considered less vulnerable than children
under five, IDI and FGD participants often mentioned this
group’s capacity to earn money to buy nets for themselves
as a rationale for assigning them lower priority. Only occasionally did participants offer a non-biological rationale
contrary to program priorities, such as the FGD participant
who said she would give the best net to the older man,
“because if he got sick, I would still be the one to suffer
with the medical bills.” [Rural FGD, Luwero]
The questionnaires from households with too few nets
to cover all sleeping spaces reveal a more complex story.
A substantial proportion—12 out of 29—of children
under five in this subsample slept without a net. These
12 children were spread across nine households in the
17-household subsample. In all but one of these nine
households, others were prioritized in receiving a net. In
theory, these eight households could have reallocated a
net from one sleeping space to another to achieve greater
coverage of children under five. The lone net in the ninth
household was used for a sleeping space with an infant; a
four-year old slept elsewhere. Adults who received a net
when children under five did not were typically heads of
household sleeping alone or with an adult partner.
The fact that a household could theoretically reallocate
nets to achieve greater coverage of children under five
does not imply that it completely disregards young children in allocating nets. Half of the eight study households
in this position were achieving partial coverage of their
children under five. The data in these cases offer minimal
information about the net allocation logic being used. For
example, one possibility is that households allocate nets
first to protect some of the young children, and then to
protect the household head or others. An alternative scenario is that they first allocate nets to household heads,
then see which children under five they can protect with
the remaining nets. A reasonable interpretation of the data
would be that children under five are not always being prioritized, that household heads and others do sometimes
receive nets to the exclusion of children under five, and
that in some cases this may reflect balancing protection of
some of the household’s young children with protection of
other household members, rather than complete disregard
of all young children and malaria programme priorities.
Page 9 of 11
Moreover, why some households allocate nets to less
biologically vulnerable members in preference to those
with greater vulnerability remains unclear. One possible
explanation is economic, as some studies suggest that
families allocate health resources to those “perceived as a
productive asset for the household” [26,27]. As primary
wage earners and caretakers, household heads may receive
better nets and sleeping spaces. However, these studies
look at health expenditures in general, not those specifically related to malaria. Further, they focus on curative rather than preventive care. One suggestion that perceived
productivity may play a role in net allocation comes from a
participant in the peri-urban Ibanda women’s focus group:
“Mzee [the old man pictured in the exercise] and Joseph
[a man meant to appear in his late 50s] are on the mat
and with no mosquito net because they are old and no
longer useful. Even if they get malaria, we won’t bother.”
When the moderator asked if other participants
agree, they responded in unison that they did. But the
comment related to older men, not to young children
or pregnant women.
The Nebbi participant who slept on the floor with her
children while her husband slept on the bed mentioned
three factors: deference to her husband’s position as
household head, a bed too small for more than one
person, and perceived inability to hang the net over a
mat. During her interview, she mentioned that her
husband had been away for some time, yet she and the
children continued to sleep on the mat. The net and
bed remained empty. It is not clear which of her three
reasons, if any, takes precedence. Her story is consistent
with Alaii et al.’s observation that in Kenya, “ITNs were
not readily redeployed in the face of shifting sleeping
patterns” [15]. Perhaps households see nets as belonging
to a particular individual or sleeping space and thus not
available for reallocation when that person is away or
that bed unoccupied. To the authors’ knowledge, there
is no literature on this question, and it warrants additional research. Similar factors may be at play in the
two households which had an extra net for one sleeping
space while another space had none.
Limitations
Several limitations preclude definitive conclusions on the
dynamics of intra-household net allocation. First, the descriptive statistics presented above cannot be generalized to
the broader population since the study participants did not
come from a random sample. The data indicate that the
most biologically vulnerable individuals are not always prioritized, despite a relative consensus to the contrary expressed
during the hypothetical exercise. However, the study was
not designed to quantify the degree to which this occurs.
Lam et al. Malaria Journal 2014, 13:183
http://www.malariajournal.com/content/13/1/183
Second, SSQ participants were not asked explicitly about
what factors influenced their actual net allocation decisions.
It may be beneficial to conduct SSQs on a larger sample of
households, and randomly select a proportion of these
households for in-depth interviews. Even in the case of a
small, non-random sample, it would be useful to explore
with respondents the reasons for allocating nets as they do.
Finally, participants interpreted the hypothetical net
allocation exercise in different ways. Most created stories around the people in the photographs, attributing
different characteristics and familial relationships to
them. This is both a strength and a weakness. On the
one hand, participants drew upon these individuallycrafted narratives in their allocation decisions, thus providing a wealth of information about social norms. On
the other hand, the differences between the narratives
limit their usefulness for drawing cross-cutting conclusions. Nonetheless, the results make clear that criteria
unrelated to biological vulnerability remain important
in intra-household net allocation, reflecting a need for
both continued research and additional resources to
improve bed net coverage within the household.
Conclusions
This research showed that in both a hypothetical exercise
and in reality, the most biologically vulnerable household
members usually receive nets when there are too few nets
to protect everyone. This is consistent with malaria behaviour change and health education messages. However,
the observed patterns of intra-household net allocation
suggest that criteria other than biological vulnerability
also play an important role. More research about what
specific criteria other than biological vulnerability factor
into these decisions would help improve the effectiveness
of messages promoting LLIN use in households with insufficient nets to cover every sleeping space. Programme
managers could then design messages to accompany distribution efforts that acknowledge and address households’ concerns in this domain, rather than only stressing
the vulnerability of young children and pregnant women
to malaria. At the same time, the results of this study
highlight the need to strengthen net distribution efforts
so that households are less frequently forced to prioritize
certain members over others.
Competing interests
The authors declare that they have no competing interest.
Authors’ contributions
YL was responsible for data analysis and interpretation as well as drafting
and managing edits to the manuscript. SH participated in study design and
data collection, and provided oversight and input throughout data collection
and analysis. SH also made substantial contributions to drafting and revising
the manuscript. AM was involved in data analysis and interpretation and
made significant contributions to the manuscript. DM oversaw data
collection and provided significant feedback on the manuscript. DL
participated in study design, oversaw data collection during both phases
Page 10 of 11
of research and provided feedback on the manuscript. AK helped manage
data collection and reviewed the manuscript. RW designed the initial
study, supervised and participated in phase 1 data collection, and
provided feedback on the manuscript. All authors reviewed and approved
the final manuscript.
Acknowledgements
This study was funded under the NetWorks project, made possible by the
generous support of the American people through the US Agency for
International Development under the President’s Malaria Initiative,
cooperative agreement GHS-A-00-09-00014. The contents are the responsibility
of the authors and do not necessarily reflect the views of USAID or the United
States Government.
The authors are grateful to the study participants for their time, patience,
and wealth of information. Thanks also to the interviewers from Team
Initiatives who conducted in-depth interviews and focus groups in five local
languages across the different regions of Uganda. Finally, special thanks to
Angela Acosta, Gabrielle Hunter, Hannah Koenker, and Matt Lynch for
providing feedback on drafts of the manuscript, to Melinda Brown for
helping with parts of the analysis and literature review, to Jessica Rothstein
for helping with parts of the analysis and with the references, and to Emily
Ricotta for the study site map presented as Figure 1.
Author details
Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street,
Baltimore, MD 21205, USA. 2Johns Hopkins Bloomberg School of Public
Health Center for Communication Programs, 111 Market Place, Suite 310,
Baltimore, MD 21202, USA. 3Makerere University, School of Social Sciences, P.O.
Box 7062, Kampala, Uganda. 4Team Initiatives Ltd, P.O. Box 3963, Teachers
House, Plot 28/30 Bombo Road, Kampala, Uganda.
1
Received: 11 March 2014 Accepted: 7 May 2014
Published: 17 May 2014
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doi:10.1186/1475-2875-13-183
Cite this article as: Lam et al.: Decision-making on intra-household
allocation of bed nets in Uganda: do households prioritize the most
vulnerable members? Malaria Journal 2014 13:183.
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