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Adherence with permethrin-treated bed net (ITN) use and their proper deployment was directly observed in 2,178 individuals (784 households) participating in a large-scale trial of ITNs on child mortality in western Kenya. The ITNs were distributed free of charge to ensure high coverage, resulting in a ratio of 1.46 persons per ITN. Approximately 30% of ITNs present were unused. The overall percentage adherence was 72.3%. The probability of adherence by individuals depended strongly on age (relative risk [RR] = 0.86, 95% confidence limit [CL] - 0.78–0.94), in which children less than five years of age were less likely to use ITNs than older individuals, and temperature, in which ITNs were more likely to be used in periods of cooler weather. A marginally significant diminution in adherence during the second year of the project was also observed (RR = 0.83, 95% CL = 0.68–1.01). Mosquito numbers, relative wealth, number of house occupants, and the educational level of the head of the household had no effect on adherence. In unstructured questioning of house residents, excessive heat was often cited as a reason for not deploying the child’s ITN. The most important reason for non-adherence was disruption of sleeping arrangements, indicating that ITNs were not readily redeployed in the face of shifting sleeping patterns due to visitors, funerals, house construction, and other events. Challenges faced by health education programs to maximize adherence with ITN use are discussed.
Acknowledgments: We thank the field staff for their assistance in the adherence survey and in the collection of mosquitoes, and the residents of Asembo for welcoming us into their homes and for their cooperation during this study. We are grateful to S. Patrick Kachur for his insights on behavioral issues affecting ITN use. We also thank Drs. Kevin DeCock and Larry Slutsker and Professor Bob Snow for reviewing the manuscript. This paper has been published with the permission of the Director of the Kenya Medical Research Institute.
Financial support: The ITN project was funded by the United States Agency for International Development. Jane A. Alaii received support from the Netherlands Foundation for the Advancement of Tropical Research (WOTRO) and the Kenya Medical Research Institute.
Disclaimer: The opinions or assertions contained in this manuscript are the private ones of the authors and are not to be construed as official or reflecting the views of the U.S. Public Health Service or Department of Health and Human Services. Use of trade names is for identification only and does not imply endorsement by the U.S. Public Health Service or Department of Health and Human Services.
Authors’ addresses: Jane A. Alaii, John M. Vulule, Amos Odhacha, and Aggrey J. Oloo, Centre for Vector Biology and Control Research, Kenya Medical Research Institute, PO Box 1578, Kisumu, Kenya. William A. Hawley, Margarette S. Kolczak, Feiko O. ter Kuile, John E. Gimnig, and Penelope A. Phillips-Howard, Division of Parasitic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Mailstop F-22, 4770 Buford Highway, Atlanta, GA 30341. Bernard L. Nahlen, Roll Back Malaria, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland.
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