NetWorks is dedicated to advancing the field of malaria prevention through operations research and formative research activities. The project uses the results of this research to understand results, improve implementation strategies and feed new information into decision-making.


New Publications

“You need to take care of it like you take care of your soul”: perceptions and behaviours related to mosquito net damage, care, and repair in Senegal

Maintaining longevity of bed nets is a cost-effective measure and essential in protection against malaria. New qualitative research in Senegal studies net use behaviours in order to inform BCC campaigns to motivate bed net users on repair of bed nets and proper handling of nets in the home. Abstract    PDF(1.2MB)


“We are supposed to take care of it”: a qualitative examination of care and repair behaviour of LLINs in Nasarawa State, Nigeria

In this study, focus group discussions and in-depth interviews provide insight into the motivating factors and barriers that influence net users perceptions and behaviors in net care and net repair. Abstract    PDF (975KB)


Recent Publications

Recalculating the net use gap: a multi-country comparison of ITN use versus ITN access

Koenker and colleagues applied Roll Back Malaria’s Monitoring and Evaluation Reference Group’s two newly defined indicators for ITN programs: the proportion of households with one ITN for every two people (“household access”) and the proportion of the population with access to an ITN within the household (“population access”) to 41 Demographic and Health Surveys and Malaria Indicator Surveys. Their aim was to recalculate the net use gap to show more accurately what percentage of people aren’t using nets when they have one available. They found that on the whole, 89% of people with access to a net within their household were using one, and that rates of net use were higher in countries where access to nets was over 50%.

Koenker H, Kilian A (2014) Recalculating the Net Use Gap: A Multi-Country Comparison of ITN Use versus ITN Access. PLoS ONE 9(5): e97496. doi:10.1371/journal.pone.0097496  Full article


Are pregnant women prioritized for bed nets? An assessment using survey data from 10 African countries

Pregnant women and newborns are the most vulnerable to the threat of malaria and, in the past, their prioritization as part of an overall malaria control campaign has been standard practice. However, within recent years, there has been a decided shift. Often, key strategies of malaria control campaigns, particularly the distribution of insecticide-treated nets, now focus on ensuring universal coverage rather than on targeting vulnerable populations. These campaigns strive to provide every household with sufficient access to nets, regardless of household composition. This study examines the impact of the shift towards universal coverage. Its detailed analysis reveals important findings that can help ensure malaria control campaigns effectively protect those most vulnerable to the disease.

Ricotta E, Koenker H, Kilian A, Lynch M. Are pregnant women prioritized for bed nets? An assessment using survey data from 10 African countries. Glob Health Sci Pract. 2014;2(2):165-172.  Abstract   Full Article (PDF 193KB)


Decision-making on intra-household allocation of bed nets in Uganda: do households prioritize the most vulnerable members?

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. 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. 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.

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. Abstract   Full Article (PDF 1.8MB)


Evaluation of a South Sudan Community–based LLIN Continuous Distribution Pilot, Lainya County, Central Equatoria State

Final Evaluation Report (February 2014). The evaluation of a community-based continuous distribution of LLINs pilot in South Sudan finds an increase in ownership of nets at the household level. The pilot was conducted in one county of South Sudan to stimulate demand for nets in households without enough nets or to replace damaged nets. Report (PDF 1.84MB)


Behaviour change communication: A tipping point for global malaria prevention efforts

Behaviour change communication (BCC)—utilizing a range of communication activities to promote healthy behaviours—is becoming increasingly essential to global efforts to eliminate malaria.  This commentary details key ways BCC adds value and improves the effectiveness of large-scale malaria prevention efforts. For example, an important attribute of BCC is the ability to encourage targeted behaviours to overcome lasting barriers to malaria elimination—in one study, exposure to BCC messages boosted rates of net use by as much as 15 percent. The bottom line, the article states, is that given the significant return on investment BCC must be recognized as critical to large-scale malaria prevention efforts.  

Koenker et al.: Strategic roles for behaviour change communication in a changing malaria landscape. Malaria Journal 2014, 13:1 doi:10.1186/1475-2875-13-1.


“People will say that I am proud”: a qualitative study of barriers to bed net use away from home in four Ugandan districts

Malaria Journal 2014, 13:82  Abstract   Full Article (PDF 521KB)


Sustaining Fragile Gains: The Need to Maintain Coverage with Long-Lasting Insecticidal Nets for Malaria Control and Likely Implications of Not Doing So 

 DOI: 10.1371/journal.pone.0083816


Analysing and recommending options for maintaining universal coverage with long-lasting insecticidal nets: the case of Tanzania in 2011

Malaria Journal 2013 12:337. Abstract   Full article (PDF 2.3MB)


Shedding light on “useful net life” from the perspective of net-owning communities in Senegal

Long-lasting insecticidal nets (LLIN) are essential components of global malaria prevention efforts. To better manage availability and distribution of LLIN that have a limited lifespan, it is important to understand how households determine when a net has reached expired status. Using qualitative methods, this study explores the net users’ perception of the life span of a net and the variable criteria households use to determine when to dispose of or repurpose a net. The findings reveal the critical need for objective, strategic guidance on how to extend the life of nets already in use, and how to effectively determine when a net no longer provides an adequate level of protection.

Loll et al.: User-determined end of net life in Senegal: a qualitative assessment of decision-making related to the retirement of expired nets. Malaria Journal 2013 12:337. Abstract   Full article (PDF 225KB)


Understanding net use behaviors in areas with significant reduction of malaria transmission, Tanzania

Malaria control is reliant on continued use of long-lasting insecticidal nets (LLINs) even in areas where the threat of malaria has been reduced. The study was conducted in two regions of Tanzania that have seen a significant reduction in malaria transmission. Focus group discussions were conducted to better understand how changes in participants’ perceived risk influence their net use. As well, the study explored in more detail the benefits of net use that are unrelated to malaria. Overall, the study’s findings provide a richer understanding of net use behaviors in communities where risk to malaria is low. The study’s findings suggest future behavior change campaigns should emphasize the non-malaria benefits as a way to provide a long-term rationale for consistent net use in communities where the threat of malaria has been greatly reduced.

Koenker H, Loll D, Rweyemamu D, Ali AS. A good night’s sleep and the habit of net use: perceptions of risk and reasons for bed net use in Bukoba and Zanzibar. Malaria Journal 2013, 12:203 Abstract   Full article (PDF 565KB)


Universal coverage with insecticide-treated nets – applying the revised indicators for ownership and use to the Nigeria 2010 malaria indicator survey data.

Malaria Journal 2013, 12:314    Abstract    Full Article PDF (1.0MB)


Addressing the gap between net ownership and use: Lessons from the culture of net use study

Understanding the context of net use in Senegal, particularly the barriers to consistent use, is discussed.

Dana Loll, et al. Poster presentation at APHA, Boston, MA, Nov. 2-6, 2013. Poster PDF (978KB)


Importance of factors determining the effective lifetime of a mass, long-lasting, insecticidal net distribution: a sensitivity analysis

Malaria Journal 2012, 11:20. Abstract   Full article PDF (3.4MB)


Examining frequency of weekly net use by children across rural, central Tanzania

The research stands; consistent use of long-lasting insecticidal nets is one of the most effective ways to prevent malaria in young children. This open access study examines how communities in rural Tanzania used nets in their households – particularly analyzing how frequently young children were prioritized for net use. The study’s findings reveal the youngest children in the household, along with their caretakers, were most likely to sleep under a protective net at night. While frequency of weekly net use declined as children rose in age, the study’s findings suggest increasing the number of nets available in the household will likely boost the rate of net use for older children as well.

Koenker et al.: Trends in weekly reported net use by children during and after rainy season in central Tanzania. Malaria Journal 2012 11:218. Abstract   Full article PDF (758)


Research Activities by Country

Currently, NetWorks is leading research on LLIN access and use among the general population and among pregnant women, with papers forthcoming.

In the first year, NetWorks led research in net quantification for planning, using analysis from 15 Demographic and Health Surveys to show that using a 2 people per net algorithm to calculate procurement needs is insufficient to reach universal coverage operationally, due to the number of households that have odd numbers of inhabitants. A planning ratio of 1.6-1.8 people per net takes into account the odd-numbered households, as well as population estimates that are outdated or otherwise insufficient, due to shifting seasonal laborer populations and other issues. 



NetWorks is addressing the issue of how to take into account nets that are already in the field due to prior distributions and/or social marketing efforts. The Senegal universal coverage activities are one method of accounting for existing nets, and we have completed a large-scale evaluation of this innovative strategy.  The evaluation is in the process of being finalized and gives some encouraging results.

NetWorks launched the first phase of Senegal Culture of Net Use study in January 2012, in order to look further into the dynamics of household net allocation and use, and to understand the gap between distribution and sleeping space coverage.  This longitudinal study collected in-depth qualitative and quantitative data on net use, net allocation, net condition, and care and repair of nets.  Over an 18 month period, households were visited three times to understand how these factors and decisions change over time.  A phase one report outlining major findings is available. Data collection for the second phase of this study was conducted in August 2012; one paper has been published and two more are in progress.

Senegal Culture of Net Use Phase One report on major findings PDF (109KB)

User-determined end of net life in Senegal: a qualitative assessment of decision-making related to the retirement of expired nets. Malaria Journal 2013 12:337. Abstract  Full article PDF (225KB)

This study design has been replicated on a smaller scale in Mali and Uganda in order to add to the knowledge base and provide a site in East Africa for comparison.

Activities in Senegal



NetWorks implemented a study evaluating the integrated net distribution campaign that UNICEF carried out in Sokoto State, Nigeria, comparing its results with that of a stand-alone net distribution campaign in a neighboring state. NetWorks is also designing and implementing post-campaign evaluations of pilot routine distributions in Nasarawa and Cross River states, which target community distribution and school-based distribution respectively. Endline results for these studies are expected in mid 2014.

NetWorks launched operational research to assess whether net care and repair BCC campaign in Nasarawa State Nigeria would increase the useable life of a net through improved net care and repair behaviors.  The research team first conducted qualitative formative research to understand existing net care and repair behaviors as well as motivations and barriers for implementing these practices. Results from this assessment were shared and utilized during the campaign design workshop, and the tools used and materials developed are available in an online toolkit, the Care and Repair of Mosquito Nets Toolkit. The campaign will be evaluated using a quasi-experimental design with baseline and endline surveys conducted in the target district as well as a control district. The baseline and midline surveys have been conducted, and the endline surveys will occur in March 2014. The care and repair study and intervention will also be replicated in Uganda.

These surveys include a quantitative durability assessment, which is used to assess the condition of nets in both sites within Nasarawa state. The same survey will be administered in Zamfara state and Cross River state in order to understand the durability of nets in three ecological zones in Nigeria. Preliminary results indicate that Zamfara and Cross River States have similar patterns of net attrition and integrity, while Nasarawa State campaign nets are developing holes at a faster rate.

Net Care and Repair Formative Research Report, Nasarawa, Nigeria PDF (562KB)

Activities in Nigeria



In Uganda, NetWorks evaluated a Hang-Up campaign using a cluster randomized, controlled community intervention design to assess the impact of household visits by volunteers on net use. This evaluation found that hang-up visits had no significant effect on net hanging and use.  NetWorks also launched a Culture of Net Use study in March 2012 and a final report has been completed. The second phase of the qualitative, longitudinal study took place in early 2013, and two papers on allocation of nets to family members and on barriers to use of nets while sleeping away from home are forthcoming. NetWorks launched a net care and repair BCC campaign in April in Serere district, eastern Uganda to understand the feasibility of increasing the useable life of nets through net care and repair behaviors in addition to motivations and barriers for implementing these practices. This study will provide a comparison to the care and repair BCC campaign and research in Nigeria. Results from the formative research in Nasarawa State showed that net care and repair behaviors are at a base level of knowledge and awareness. A midterm qualitative assessment on net care and repair was conducted in September 2013 in the intervention district, Serere, and the control district, Kaliro, Uganda, and has informed the second phase of the BCC campaign. Similar to Nigeria, the campaign will be evaluated using a quasi-experimental design with baseline and endline surveys conducted in the target district as well as the control district. The baseline survey was conducted in November 2012 and the follow-up survey will occur in April 2014.

Uganda Culture of Net Use Study Phase One Findings PDF (846MB)

Activities in Uganda



In Tanzania, NetWorks has conducted formative research in Kagera and Zanzibar on messaging to encourage community members to use nets in the context of reduced malaria transmission settings. Kagera and Zanzibar have been especially successful in reducing their incidence of malaria through IRS (indoor residual spraying), and distribution and promotion of nets.  The study revealed that while the majority of people continued to use their nets in order to prevent malaria, a significant portion of them also reported that getting a good night’s sleep was also a key motivator, and that the net protected them from both biting pests and the worries of getting malaria {Koenker 2013}. Many reported that they were now in the habit of using the net, and didn’t feel comfortable sleeping without one. BCC messaging is now moving towards promoting use of nets for these non-malaria reasons, to further encourage net use even when the risk of malaria is perceived to be low.

In addition, NetWorks conducted a mixed methods evaluation of the Community Change Agent (CCA) program in Tanzania. This program uses community health workers to promote net use and provide information about malaria and proper use of nets. The evaluation consisted of quantitative and qualitative inquiry among both the CCAs themselves as well as community members. The data has been collected and is being analyzed to understand the role of CCAs and other communication channels in promoting net use in Tanzania.


Greater Mekong Subregion

NetWorks is conducting three research activities in Cambodia, Laos and Myanmar. A study on consumer preferences for malaria prevention is planned in Cambodia and Myanmar, along with a qualitative assessment on personal protective measures in Laos for those living and working in the Forest Triangle Region. Following a recent LLIN distribution in Myanmar, a rapid coverage assessment is planned for selected districts, to measure LLIN ownership and use. Results from these studies will inform planning and procurement of targeted malaria prevention tools appropriate for various target groups.



In 2012 NetWorks conducted a Culture of Net Use study in Mali, in Sikasso and Kayes regions. The study found that net use is high in Mali, and higher in the region covered by the universal distribution campaign than in the region not yet covered. Sources of nets differed across the sites, with a significant number of nets in Kayes bought at the market, but free nets are highly valued and there is no decline in perceived quality or value with the distribution of free nets. Net care and repair practices were not common, and more communication on this topic may help improve the useful life of nets in households.