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Strategies to increase the ownership and use of insecticide-treated bednets to prevent malaria

Additional Info

  • Authors: Lana Augustincic Polec, Jennifer Petkovic, Vivian Andrea Welch, Erin Ueffing, Elizabeth Tanjong Ghogomu, Jordi Pardo Pardo, Mark Grabowsky, Amir Attaran, George A. Wells, Peter Tugwell
  • Published date: 2015-11-02
  • Coordinating group(s): International Development
  • Type of document: Review, Plain language summary
  • See the full review:

About this systematic review

This Campbell systematic review assesses the effectiveness of economic and educational strategies for ownership and appropriate use of insecticide-treated bednets in developing countries. The review also examines whether changes in ITN ownership and use affect malaria-specific morbidity rates. The review summarises findings from 10 studies, nine of which were conducted in rural Africa and one in rural India.

What are the main results?

Compared to providing ITNS at full market or a subsidized price, giving away ITNs for free increases the number of people owning an ITN. However, the provision of free ITNs increases their use only slightly or not at all.

Providing education in the appropriate use of ITNs increases the number of people sleeping under bednets compared to a control group which didn’t receive the education.

Combining these strategies with unspecified incentives does not increase ITN ownership, leading to little or no differences in their appropriate use. Embedding the promotion of ITNs within specific health- or finance-focused marketing messages only leads to small or no differences in bednet ownership and use.

There is some evidence of improved malaria-specific morbidities among children and adults as a result of increased ITN ownership and use. However, the evidence supporting this finding is of low certainty and should be interpreted with caution.


Malaria is a life-threatening parasitic disease and 40% of the world's population lives in areas affected by malaria. Insecticide-treated bednets (ITNs) effectively prevent malaria, however, barriers to their use have been identified.


To assess the evidence on the effectiveness of available strategies that focus on delivery and appropriate use of ITNs.

Search methods

We searched the EPOC Register of Studies, CENTRAL, MEDLINE, EMBASE, HealthStar, CINAHL, PubMed, Science Citation Index, ProQuest Dissertations and Theses, African Index Medicus (AIM), World Health Organization Library and Information Networks for Knowledge (WHOLIS), LILACS, Virtual Health Library (VHL), and the World Health Organization Library Information System (WHOLIS). Initial searches were conducted in May 2011, updated in March 2012 and February 2013. Authors contacted organizations and individuals involved in ITN distribution programs or research to identify current initiatives, studies or unpublished data, and searched reference lists of relevant reviews and studies.

Selection criteria

Randomized controlled trials (RCTs), non-randomized controlled trials, controlled before-after (CBA) studies, and interrupted time series evaluating interventions focused on increasing ITN ownership and use were considered. The populations of interest were individuals in malaria-endemic areas.

Data collection and analysis

Two authors independently screened studies to be included. They extracted data from the selected studies and assessed the risk of bias. For RCTs, we used the Cochrane Collaboration’s 'Risk of bias' tool and we used the risk of bias criteria suggested by EPOC for other study designs. When consensus was not reached, any disagreements were discussed with a third author. The magnitude of effect and quality of evidence for each outcome was assessed.


Of the 3,032 possibly relevant records identified, 10 studies were included in this review; eight cluster RCTs, one RCT, and one CBA study. Overall, three studies were assessed as having moderate risk of bias and seven studies were assessed as high risk of bias. Effect of ITN cost on ownership: Four studies including 4,566 households and another study comprising 424 participants evaluated the effect of ITN price on ownership. These studies suggest that providing free ITNs probably increases ITN ownership when compared to subsidized ITNs or ITNs offered at full market price. Pooled data for two studies suggested that receiving an ITN at no cost probably increases ITN ownership, compared to purchasing an ITN at the market price (SMD 0.69, 95% confidence interval (CI) 0.39 to 0.99, moderate-certainty evidence) or purchasing an ITN using a loan (SMD 0.37, 95% CI 0.27 to 0.47, moderate-certainty evidence). There is probably little to no difference in ITN ownership when comparing groups in which ITNs were purchased using a loan and those in which ITNs were purchased at the market price (SMD 0.29, 95% CI -0.06 to 0.63, moderate-certainty evidence). Effect of ITN cost on appropriate use of ITNs: Three studies including 9,968 households and another study comprising 259 individuals found that there is probably little or no difference in the use of ITNs when they are provided free, compared to providing subsidized ITNs or ITNs offered at full market price. Effect of education interventions on use of ITNs: Five studies, including 12,637 households, assessed educational interventions regarding ITN use and concluded that education may increase the number of adults and children using ITNs (sleeping under ITNs) compared to no education. One study, including 519 households, assessed the effects of providing an incentive (an undisclosed prize) to promote ITN ownership and use, and found that incentives probably lead to little or no difference in ownership or use of ITNs, compared to not receiving an incentive. None of the included studies reported on adverse effects.

Implications for policy and research

Five studies examined the effect of price on ITN ownership and found moderate-certainty evidence that ownership was highest among the groups who received the ITN free versus those who purchased the ITN at any cost. In other words, demand for ITNs is elastic with regard to price and hence subsidies (providing full or partial cost recovery) will probably increase ownership. However, once the ITN is supplied, the price paid for the ITN probably has little to no effect on its use; the four studies addressing this outcome failed to confirm the hypothesis that people who purchase nets will use them more than those who receive them at no cost. Educational interventions for promoting ITN use have an additional positive effect. In other words, the evidence suggests that ITN use is highly inelastic with respect to price, and therefore additional encouragement (such as through education) is probably needed to promote appropriate use, over and above any subsidies to increase ownership. However, the impact of different types or intensities of education is unknown.


Other keywords: Lower- and middle-income countries (LMIC)

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