scope and extent of alternative use of bed nets within the

Scope and Extent of Alternative Use of Bed Nets within the Arsi Zone in Ethiopia:

Preliminary Findings from Household Interviews and Observations

May 2012

Scope and Extent of Alternative Use of Bed Nets within the Arsi Zone in Ethiopia: Preliminary Findings from Household Interviews and Observations

C‐Change May 2012

This publication is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of Agreement No. GPO‐A‐00‐07‐00004‐00. The contents are the responsibility of the C‐Change project, managed by FHI 360, and do not necessarily reflect the views of USAID or the United States Government.

Recommended Citation

C‐Change. 2012. Scope and Extent of Alternative Use of Bed Nets within the Arsi Zone in Ethiopia: Preliminary Findings from Household Interviews and Observations. Washington, DC: C‐Change Project, FHI 360.

Cover photo: A bed net is used to curtain a door of a house in the Arsi Zone.

C‐Change photo.

Contact Information

C‐Change FHI 360 1825 Connecticut Avenue, NW Washington, DC 20009 Phone: (202) 884‐8000 Fax: (202) 464‐3799 www.c‐changeproject.org

C‐Change is a USAID‐funded project implemented by FHI 360 and its partners:

CARE; Internews; Ohio University; IDEO; Center for Media Studies, India; New

Concept, India; Soul City, South Africa; Social Surveys, South Africa; and Straight

Talk, Uganda.

Contents

Executive Summary ....................................................................................................................................... 1

Background ................................................................................................................................................... 3

Objectives ..................................................................................................................................................... 4

Methods ........................................................................................................................................................ 5

Results ........................................................................................................................................................... 6

Summary and Discussion ............................................................................................................................ 12

Programmatic Implications ......................................................................................................................... 13

References .................................................................................................................................................. 14

Tables

Table 1. Bed nets received and owned by households ................................................................................................. 6

Table 2. Bed nets owned observed and used among all households ............................................................................ 7

Table 3. Bed nets used for malaria prevention among households where at least one net was observed .................. 8

Table 4. Alternative use of whole and partial bed nets among households where at least one net was observed ..... 8

Table 5. Alternative and intended bed use among households where at least one net is used for any purpose......... 9

Table 6. Bed net use for malaria prevention and protective, alternative uses .......................................................... 10

Table 7. Bed net use for malaria‐prevention and non‐ protective alternative uses .................................................... 11

Table 8. Proportion of bed nets used for alternative uses that provide some or no protection against malaria ....... 12

Acknowledgments

Seven independent consultants collected qualitative and quantitative data, transcribed and translated group interviews, and conducted the preliminary analysis: Gizaw Abera , Amiti Abasemel, Tsige Alemu, Emnet Asfaw, Meseret Befekadu, Refera Chala, Bichaka Degefa. Celeste Marion, independent consultant, reviewed the initial findings and conducted additional analysis.

The following C‐Change Ethiopia staff provided logistical support for the study: Shoa Girma (Chief of Party); Henock Gezahegne (Malaria Program Sirector ) Eskinder Tenew (M&E Advisor); Bayissa Urgesa (Community Mobilization Coordinator); Akrem Abdusemed (Regional Liaison Officer ) Adanech Dutu (Training Supervisor); Abreham Girma (Training Supervisor); Getahun Negussie (Arsi Zonal Coordinator); Eyob Weldegebreil (Logistic Officer); and Solomone Tesfaye (Finance and Operations Manager). In addition, Eskinder Tenew provided technical assistance on the design the sampling strategy and sample size determination. Shoa Girma reviewed drafts of the study protocol and report. Adanech Dutu conducted interviews and supervised data collection.

From C‐Change headquarters, Hibist Astatke and Thaddeus Pennas developed the study questions. Hibist Astatke designed the study, led the implementation team and prepared the study report. Neill McKee, Antje Becker‐Benton, and Thaddeus Pennas provided comments on the study protocol and technical reviews of drafts. Patricia Choi conducted a literature search and wrote up findings, and Hilary Russell edited the final draft.

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Executive Summary

Background: The use of long‐lasting, insecticide‐treated nets (LLINs) is one of the cornerstones of the President’s Malaria Initiative’s strategy for malaria prevention and control in sub‐Saharan Africa. As a result of free or subsidized LLIN‐distribution efforts in recent years, LLIN ownership and use have increased in many countries, though use has tended to lag behind ownership. Anecdotal media reports and a few localized studies have highlighted the use of bed nets for purposes other than malaria prevention and raised questions about the potential negative impact of alternative uses. Concerns have also been expressed about the environmental impact of alternative uses and incorrect disposal of bed nets.

Given the need to determine the scope of alternative uses of bed nets and explore potential implications for intended use, the C‐Change Project conducted a pilot study in the Arsi Zone in Ethiopia in May 2011 to assess intended and alternative use of bed nets and develop methods for future studies. Because of the limited number of systematic research studies on this topic, plans for a rapid assessment were revised to include more rigorous quantitative sampling methods and analysis. At the donor’s request, comparison households were included to allow for observations of alterative and intended use in communities where LLIN distribution was not accompanied by C‐Change’s social and behavior change communication (SBCC) activities.

Objectives: The primary objective of the pilot study was to provide data on the scope and extent of alternative use of bed nets in intervention and comparison communities and to identify barriers and facilitators for intended and alternative uses. A secondary objective was to provide recommendations on future monitoring studies and the design of SBCC programs that promote LLIN use and malaria prevention and control. Methods: A cross‐sectional survey was used to measure the scope and extent of alternative and intended use of bed nets at the household level. Qualitative methods were used to explore barriers and facilitators for intended and alternative use. Intervention communities in the Arsi Zone were those where C‐Change SBCC activities had accompanied LLIN distribution. Comparison communities in this zone had received LLINs, but were not reached by C‐Change SBCC activities. This report includes findings from the household survey. Findings from the qualitative component will be presented in a separate report.

Results: The results of the cross‐sectional survey provide insight on alternative uses of bed nets in intervention and comparison communities within the Arsi Zone. Main findings describe similarities and differences between intervention and comparison communities.

In intervention communities, 43 percent of households had received two or more bed nets, compared to 31 percent of households in the comparison communities.

There was little difference between the mean number of bed nets that households reported they owned and the mean number of bed nets they reported they had received. In intervention communities, the mean was 1.90 for bed nets received and 1.86 for bed nets

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owned. In comparison communities, the mean was 1.36 for bed nets received and 1.42 for bed nets owned. This suggests high retention of distributed bed nets in both communities.

Bed net ownership was high in both communities: 96 percent of households in intervention communities and 99 percent of households in comparison communities.

In intervention communities, 46 percent of households used a bed net for malaria prevention the night before the survey, compared to 20 percent of households in comparison communities.

In intervention communities, 37 percent of households used bed nets for alternative purposes, compared to 56 percent of the households in comparison communities.

In both communities, only a small percentage of households used bed nets simultaneously for malaria prevention and alternative purposes: 15 percent in intervention communities and 4 percent in comparison communities.

A variety of alternative uses was observed within homes and compounds. Bed nets were being used as bed sheets, mattress covers, room partitions, and covers or sidewalls for outdoor toilets. These alternative uses provide some protection against malaria. Other alternative uses were specific to farming households and provide no protection against malaria, including the use of bed nets to cover grain, make rope for ploughs, and create livestock stables.

Discussion: The findings show that reported bed net ownership in intervention communities was nearly two bed nets per household in intervention communities. The retention and availability of bed nets are both high in intervention and comparison communities. However, bed net use for malaria prevention was higher in the intervention communities, while higher alternative use was observed in comparison communities. C‐Change’s SBCC interventions likely contributed to these differences between intervention and comparison households and to the narrower gap between bed net ownership and bed net use in intervention communities. Study limitations included the non‐generalizability of the findings to other zones within the Oromia Region and potentially inflated results in comparison communities due to purposive sampling. The study design did not allow differences in use patterns between intervention and comparison communities to be fully attributable to the C‐Change SBCC program. In addition, the survey was conducted at a time not considered to be “malaria season” by survey respondents. This may have contributed to lower intended use and higher alternative use of bed nets in both intervention and comparison communities. It is recommended that existing communication strategies be further refined to better address barriers and facilitators for correct bed net use, given the low to moderate levels of alternative use observed and reported. The findings also highlight the importance of developing evidence‐based SBCC strategies by conducting studies to understand the prevalence of desired behaviors, competing behaviors, and social norms and their associated barriers and facilitators.

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Scope and Extent of Alternative Use of Bed Nets within the Arsi Zone in Ethiopia: Preliminary Findings from Household Interviews and Observations

Background

Use of long‐lasting, insecticide‐treated nets (LLINs) is one of four effective malaria prevention interventions being scaled up through the President’s Malaria Initiative (PMI) in sub‐Saharan Africa. Free or subsidized distribution of LLINs has been the main strategy for increasing universal coverage. As a result of distribution efforts by several government and non‐governmental organizations, LLIN ownership and use have increased in a number of African countries. However, national surveys in Ghana, Kenya, Senegal, and Tanzania indicate that use of LLINs has tended to lag behind LLIN ownership (Ghana Statistical Service 2008; Kenya National Bureau of Statistics 2010; Ndiaye and Ayad 2009; Tanzania Commission for AIDS 2008).

Anecdotal media reports and a small number of studies have highlighted the use of bed nets for purposes other than malaria prevention and raised questions about the potential negative impact of alternative uses on malaria control (Baume 2007; Atkinson et al. 2009; Minakawa et al. 2008). Concerns have also been expressed about the environmental impact of alternative uses and incorrect disposal of bed nets (Koehrn 2009). Some of these studies use qualitative methods, and some are localized—for example, based on samples in fishing villages.

Given the need to determine the scope of alternative uses of bed nets and explore potential implications of intended use, C‐Change conducted a pilot study in Ethiopia to assess intended and alternative use of bed nets and develop methods for future studies. The lack of systematic research on this topic prompted a revision of the initial plan for a rapid assessment and the inclusion of more rigorous quantitative sampling and analysis methods. In addition, the donor requested that comparison communities be included in the survey—those where LLIN distribution was not accompanied by social and behavior change communication (SBCC) activities.

The study was conducted in the Arsi Zone of Ethiopia, one of four zones within the Oromia Region where C‐Change has been implementing SBCC activities to scale up malaria prevention and control. Prior to the start of C‐Change’s phased implementation, the Arsi Zone had high levels of bed net ownership but lower levels of bed net use and knowledge than the three other zones in the region.

According to a 2009 baseline study in the Oromia Region, 77 percent of respondents in the Arsi zone cited sleeping under a bed net as a malaria prevention method (AED/Netmark Ethiopia 2009). This proportion ranked third among the four surveyed zones in the region. (The highest was in West Arsi–97 percent—and the lowest in West Shewa—72 percent.)

The 2009 baseline study did not report bed net use at the household level. At the time, 45 percent of households in the Arsi Zone owned at least one bed net—the highest proportion among the four zones. (The lowest proportion—25 percent—was in West Arsi). Among households owning at least one bed net in the Arsi Zone, 42 percent of household members slept under a bed net the previous night among households that owned at least one bed net.

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In the four surveyed zones in the Oromia Region, the highest proportion of household members who slept under a bed net was in West Arsi and Jimma (47 percent) and the lowest was 33 percent in East Shewa.

The Arsi Zone was selected for the pilot study because of its proximity to C‐Change’s Ethiopia office. This proximity was critical for rapid data collection, given the study’s short time period and difficulties involved in traveling to other areas. The Arsi Zone included implementation communities where LLIN distribution overlapped with a coordinated set of C‐Change SBCC activities, as well as comparison communities where SBCC programming did not accompany LLIN distribution. Inclusion of communities with and without SBCC programs accompanying LLIN distribution was important, since this allowed the potential role of SBCC programs in promoting LLIN use and reducing alternative use to be explored.

Objectives

The primary objective of the pilot study was to provide data on the scope and extent of alternative use of bed nets in intervention and comparison communities, with a focus on identifying barriers and facilitators for intended and alternative use of bed nets. A secondary objective was to provide recommendations for SBCC program design and future monitoring studies.

The study relied on a mixed‐methods approach. Quantitative methods were used to collect household‐level data, while qualitative methods were used to collect data on the barriers and facilitators of both intended and alternative use of bed nets. This report presents preliminary findings from the quantitative survey on the scope of alternative use of bed nets in intervention and comparison communities, within the context of ownership and use given the inter‐related nature of correct, alternative and non‐use of bed nets. These findings will be reported in one or more articles and submitted to peer‐reviewed journals, with the addition of data on bed net condition and disposal methods, qualitative findings on barriers and facilitators for alternative and intended use of bed nets, recommendations for program design, and lessons learned for future monitoring studies.

The study was conducted among rural and farming households in the Arsi Zone. C‐Change photo.

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Data collectors needed to overcome challenges to reach some households. C‐Change photo.

Methods

Target group: The survey focused on households in communities where LLIN distribution took place within the last two years. Women of reproductive age (15–49) responded to survey questions about alternative use of bed nets at the household level and to questions on bed net use by all household members, including pregnant women and children under 5.

Study design: A cross‐sectional study design was used to collect quantitative data on alternative and intended bed net use from intervention and comparison communities in the Arsi Zone. In intervention communities, C‐Change SBCC activities had accompanied LLIN distribution. Comparison households had received LLINs, but had not yet been reached by C‐Change activities.

Sample size: A sample size of 140 was calculated to identify point estimates for alternative use of bed nets. A .05 statistical level of significance and a .01 margin of error was used. The total sample size for both intervention and comparison communities was 280.

Sampling strategy: Separate samples were selected within intervention and comparison communities, using a two‐stage approach. The first stage was to select kebeles, the smallest government administrative units. Seven kebeles were selected from among all the malarious kebeles, using probability proportionate to size.

The intervention samples were from the woredas of Dodota, Jeju, Merti, Sire, and Zuway Dugda. In the second stage, 20 households were selected in each kebele, using a random route and quota sampling strategy.

The comparison sample was selected from the woredas of Seru and Tiyo. Surveys were conducted in Tiyo kebeles as planned. In Seru, interviewers could reach only one kebele where they conducted the survey in four “gotes” or “geres”—small communities of about 30 households.

Data collection procedures: The quantitative survey was completed with the help of female head of each household (ages 15–49) and through group interviews with three or more other household members. Interviewers gathered self‐reported data on bed net ownership and use, and they observed and noted the presence and use of whole and partial bed nets within households and compounds.

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Data collection instruments: A questionnaire was used to record information on the following areas:

1. Number of bed nets (received and owned) 2. Status of observed nets (open, in original packaging) 3. Condition of the bed nets (no tears; clean) 4. Bed net use (hung on wall or ceiling; use previous night; correct use previous night) 5. Alternative use of bed nets (entire nets; pieces of nets) 6. Disposal methods

Results

The results provide insight on alternative uses of bed nets in intervention and comparison communities within the Arsi Zone in Ethiopia. The data are presented according to similarities and differences between intervention and comparison communities. Key questions relevant for SBCC programs are used to organize the findings. Results on alternative uses are presented after data on bed net distribution, ownership, and intended use in order to provide the context within which alternative uses were observed. Different types of alternative uses are described, highlighting those that provide some protection against malaria.

Are households keeping the bed nets they receive?

Approximately two‐fifths of households in intervention communities had received two or more bed nets, compared to about one‐third of households in the comparison communities who received this number. The mean number of bed nets reportedly received and owned was nearly the same in intervention communities (M=1.90 and M=1.86). In comparison communities, the mean number of nets reported to be owned was slightly higher than the number of bed nets reportedly received (M=1.42 and M=1.36). This suggests high retention of distributed bed nets in intervention and comparison communities. It also suggests that comparison households may have had obtained bed nets by means other than mass distribution. Table 1. Bed nets received and owned by households

Intervention (%)

N=138*

Comparison (%)

N=140**

1 bed net received 34.1 66.4

2 bed net received 42.8 31.4

3 bed nets received 22.5 2.1

4 bed nets received 0.7 –

Mean # bed nets received 1.90 1.36

Mean # bed nets owned 1.86 1.42

* Mean # of bed nets owned in intervention communities is among households that received at least one bed net (N=133) **

Mean # number of nets owned in comparison communities is among households that received at least one bed net (N=138)

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What proportion of households that own bed nets use them for any purpose?

Bed nets were available for observation in over 90 percent of the intervention and comparison households that reported owning them. In intervention communities, 96 percent of households reported owning one or more bed nets, and interviewers observed at least one bed net in 92 percent of households. In comparison communities, 99 percent of households reported ownership of at least one bed net, and interviewers observed at least one bed net in 96 percent of households. When bed nets reported to be owned were not available for observation, the most frequent reason given was that they were stored in a locked trunk within the house.

Over two‐thirds of the intervention and comparison households—71 percent and 70 percent, respectively—used the observed bed nets for some purpose, whether alternative or intended. Table 2. Bed nets owned observed and used among all households

Intervention (%) Comparison (%)

Households that said they own a bed net 96.4 98.6

Households that showed interviewers a bed net 92.8 96.4

Households that used a bed net for any purpose 71.4 70.0

N 138 140

What proportion of households with at least one bed net took steps to use it for malaria prevention?

In intervention communities, 94 percent of households had at least one bed net that had been taken out of its original packaging. This initial step had been taken by 87 percent of comparison households.

More intervention households had taken the additional step of hanging the bed net from a wall or ceiling so it could be slept under. At the time of the interview, 48 percent of intervention households with at least one bed net had a bed net hanging from a wall or ceiling. This was true of only 21 percent of the comparison households.

The proportion of all households reporting that someone had slept under a bed net the previous night was 46 percent in intervention households and 19 percent in comparison households. These are almost the same percentages of households where bed nets were hanging—48 percent and 21 percent, respectively. These data are consistent with research findings that bed nets left hanging during the day are more likely to have someone sleeping under them at night (Pulford et al. 2011).

Among intervention households, the gap between the proportion with bed nets removed from their packaging and the proportion with bed nets used for malaria prevention was 48 percent. This gap was much larger—68 percent—among comparison households.

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These data suggests that while households in both communities have taken initial steps towards using bed nets for malaria prevention, a higher proportion of household has taken these steps in the intervention communities.

Table 3. Bed nets used for malaria prevention among households where at least one bed net was observed

Intervention (%)

Comparison (%)

Households with at least one bed net removed from packaging 93.8 87.4

Households with at least one bed net hung for sleeping 48.1 20.7

Households with at least bed one who person slept under a net the previous night

45.7 19.4

N 129 134

What proportion of households use whole or partial bed nets for alternative purposes?

Where bed nets were observed, alternative use was higher among comparison households than among intervention households. Among comparison households, 56 percent used at least one whole or partial bed net for an alternative purpose, compared to 37 percent of households in intervention communities. Use of at least one whole bed net for an alternative purpose was observed in 48 percent of comparison households and in 13 percent of intervention households. The use of one or more partial bed nets for alternative purposes was observed in 5 percent of comparison households and 20 percent of intervention households.

Use of whole (rather than partial) bed nets for alternative uses was reported by almost all household with alternative use in comparison communities, while partial bed nets accounted for most cases of alternative use in intervention communities. Only a very small proportion of households used both whole and partial bed nets for alternative purposes: 4 percent in intervention communities and 3 percent in comparison communities.

Table 4. Alternative use of whole and partial bed nets among households where at least one net was observed


Household with no alternative use 62.8 43.7

Household holds with alternative use of whole or partial bed nets

37.2 56.3

use of whole bed nets only 13.2 48.1

use of partial bed nets only 20.2 5.2

use of both whole bed nets and partial bed nets 3.9 3.0

N 129 135

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Is a significant proportion of households using bed nets for both alternative and intended purposes?

Among households who used at least one bed net for any purpose, bed net use for alternative purposes was three times higher—70 percent—within comparison communities than intervention communities, where 24 percent of households used bed nets for alternative purposes. Use of bed nets for malaria protection was observed in 63 percent of intervention households and among 26 percent of the comparison households. Use of whole or partial bed nets for both alternative and intended purposes was low in intervention households—15 percent—and rare in comparison households—4 percent. Table 5. Alternative and intended use among households where at least one net is used for any purpose


Households with alternative bed use of at least one net observed 23.7 70.4

Household use of at least one bed net for malaria prevention observed

63.4 26.5

Household use of alternative and intended use of whole or partial bed nets observed

15.1 4.1

N 93 98

What are the different types of alternative uses observed?

About 15 types of alternative uses were observed across intervention and comparison communities. The different types of alternative uses observed can be categorized into two groups.

In the first group are bed nets used in homes and compounds for functional or aesthetic purposes that provide marginal protection against malaria. Such uses include the use of bed nets as bed sheets, mattress covers, room partitions, and covers or side walls for outdoor toilets.

View of a bed net used for an alternative purpose. C‐Change

photo.

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In the second group are uses specific to the farming communities in this study. These uses do not provide protection against malaria, and include bed nets used to cover grain, make rope for ploughs, or create livestock stables.

Use of bed nets to transport goods was observed only in intervention communities, while their use to cover a well, dung, and livestock stalls was observed only in comparison communities.

What proportion of households use bed nets for purposes that provide some protection against malaria?

Among comparison households with bed nets, the proportion putting them to a specific alternative use that provided some protection against malaria ranged from 1 percent to 14 percent. Use as bedding was the most frequently observed alternative use. Bed nets were used as a bed sheet (13 percent), a bed spread (11 percent), and a mattress cover (14 percent). Among intervention households with bed nets, the proportion putting them to a specific alternative use that provided some protection against malaria ranged from 5 percent to 9 percent. Use as a curtain was the most frequently observed protective alternative use, among 9 percent of intervention households. Less than 5 percent of these households put bed nets to other alternative uses. Table 6. Bed net use for malaria prevention and use for protective, alternative uses


Households where at least one bed net slept under the prior night

42.8 18.6

Households where at least one bed net used for marginally protective purpose

13.3 50.4

as a bed sheet 4.3 12.9

under mattress 4.3 1.4

to cover mattress 2.2 14.3

as bed spread 1.4 11.4

as a curtain 9.4 3.6

as a room partition 2.2 .7

to cover wall or house .7 2.9

as side wall for toilet 2.9 1.4

N 137 140

What proportion of households practice alternative uses that provide no protection against malaria?

The proportion of households putting bed nets to specific, non‐protective, alternative uses ranged from 1 percent to 9 percent in intervention communities and from 1 percent to 6 percent in comparison communities.

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Among intervention households, use as rope was the most frequently observed non‐protective, alternative use (9 percent). Among comparison households, the most frequently observed non‐protective, alternative use was as a cover for grain (6 percent). Table 7. Bed net use for malaria prevention and non‐ protective alternative uses


Households where at least one bed net slept under the previous night

42.8 18.6

Households where at least one bed net used for non‐protective purpose

15.5 9.6

as string or rope 8.7 2.1

to cover grain 5.1 5.7

to cover table 2.2 .7

to pack up and transport goods .7

to cover well .7

to cover livestock stalls .7

to cover dung .7

N 137 140

What proportion of bed nets are used for alternative purposes that provide some protection against malaria? What proportion provide no protection?

While previous sections of this report used households as the unit of analysis, Table 9 presents the percentage of all bed nets—whether whole or partial—put to use for alternative purposes in comparison and intervention communities. Bed nets put to no alternative use are excluded. Across households, the proportion of bed nets used for alternative purposes that provide marginal protection against malaria was higher in comparison communities (83 percent) than in intervention communities (63 percent). In intervention communities, bed nets used as curtains accounted for the highest proportion in this category (20 percent), while bed nets used as bedding materials accounted for the highest proportion in comparison communities. In both communities, bed nets used as bed sheets accounted for over 10 percent of those put to alternative, marginally protective uses. The proportion of bed nets used for alternative purposes that provide no protection was higher in intervention communities than in comparison communities: 38 percent and 17 percent, respectively. Use of bed nets to cover or store grains accounted for the highest proportion of bed nets used for non‐protective, alternative use in both communities. Use as string or rope accounted for the highest proportion of bed nets used for non‐protective, alternative use in intervention communities.

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Table 8. Proportion of bed nets used for alternative uses that provide some or no protection against

malaria


Alternative uses that provide marginal protection 62.6 82.9

to cover mattress 4.7 25.8

as bed sheet 10.9 20.4

to cover bed 3.1 21.5

under mattress 9.4 2.2

as curtain 20.3 5.4

as room partition 6.3 1.1

as cover or side wall for outdoor toilet 6.3 2.2

Alternative uses that provide no protection 37.6 17.3

to pack up and transport goods 1.6 –

to cover dung – 1.1

to cover a well – 1.1

to cover livestock stalls – 1.1

to cover or store grain 10.9 8.6

to cover table 4.7 2.2

Total (whole and partial nets) 64 93

Summary and Discussion

Reported bed net ownership in intervention communities was nearly two bed nets per household, as mandated by the National Malaria Control Strategy. High retention and availability of distributed bed nets characterize both intervention and comparison communities.

Alternative use of bed nets was higher in comparison communities, while bed net use for malaria prevention was higher in intervention communities. The lower alternative use and higher intended use of bed nets in intervention communities suggest a positive effect of the C‐Change SBCC activities that accompanied LLIN distribution.

Bed net ownership was almost two times higher than reported bed net use for malaria prevention in intervention communities, while ownership was about four times higher than use in comparison communities. These gaps between bed net ownership and use for malaria prevention are likely due to free distribution of bed nets resulting in ownership of bed nets by more households, some of whom may be less motivated to use them. C‐Change’s SBCC activities are likely to have contributed to the narrower gap between ownership and use for malaria prevention in the intervention communities.

Simultaneous intended and alternative use of whole or partial bed nets occurred infrequently in intervention communities and rarely in comparison communities. The slightly higher proportion of intervention households that used bed nets for both intended and alternative purposes may be due to the higher proportion of intervention households with two or more bed nets.

Some alternative uses (such as for bedding) appear to provide some protection against malaria. These uses are more common in comparison communities; they were observed in about one‐half of the comparison households and about one‐tenth of intervention households. Most of

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the bed nets used for alternative purposes in intervention and comparison communities appear to provide a measure of protection against malaria.

The study limitations included non‐generalizability of the findings to other zones. The survey was designed to be an exploratory assessment of alternative bed net use in one zone within Oromia Region. The findings cannot be generalized to other zones within the Oromia region or other regions in Ethiopia. The differences found in use patterns between the intervention and comparison communities may also not be fully attributable to exposure to C‐Change SBCC interventions, since other contextual factors may have influenced these patterns.

Purposive sampling used in some comparison communities may have lead to inflated levels of alternative use in these communities. The use of bed nets for bedding materials—a marginally protective alternative use—accounts for most alternative uses in comparison households, and was mostly observed in purposively selected comparison communities. These communities are located near the top of a deep canyon where malaria endemicity is likely to be lower, compared to communities located lower down in the canyon that were less accessible to interviewers. A final limitation is the timing of the survey. It was conducted in the month of May, before what respondents considered to be malaria season. This may have contributed to lower reported use of bed nets for malaria prevention and higher alternative use in both intervention and comparison communities.

Programmatic Implications

The current C‐Change intervention in the Arsi Zone appears to be having a positive effect on intended and alternative use of bed nets. Given this it is recommended that on‐going malaria programs with low to moderate alternative use refine existing communication strategies to better address barriers and facilitators for correct bed net use, increase intended use, and decrease non‐use and alternative use.

There does not appear to be a need to develop a new, separate communication strategy that focuses on reducing alternative use in cases where low to moderate levels of alternative use are observed. This might be warranted in situations where much higher levels of alternative use that hinder or prevent intended use are observed. While large population‐level studies are important for determining the prevalence of alternative and intended bed net use at national levels, the findings highlight the importance of conducting small‐scale studies on these topics. Such studies can provide information on the prevalence of social norms, desired behaviors, and competing behaviors, and identify barriers and facilitators associated with these norms and behaviors for developing evidence‐based SBCC strategies. Such strategies should be particularly effective in increasing intended use, decreasing alternative use, and reducing the gap between bed net ownership and bed net use that often follows free distribution.

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scope and extent of alternative use of bed nets within the

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