Volume 100, Issue 6
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Distributing long-lasting insecticidal nets (LLINs) to individuals living in malaria-endemic regions is a cornerstone of global malaria control. National malaria control programs aim to achieve “universal coverage” of at-risk populations to reach LLINs’ full potential to reduce malaria, progress of which is then measured by indicators constructed from standardized questionnaires. Through an exploration of variability in LLIN use in Cambodia, we argue that indicators of universal coverage of LLINs are not sufficiently commensurate with the realities they are intended to measure, limiting the suitability of the data to serve program and policy purposes in a malaria elimination era. Reflecting on the various sources of variability in LLIN use, we apply and extend the concept of “appropriateness” as a third prong to the widely used “efficacy” and “effectiveness” criteria for evaluating LLINs as a tool for malaria prevention. Describing first the different dimensions of the intervention and the sociocultural context separately, we will further show how the variability underlying both is affected and induced by inappropriate aspects of the intervention and the measurements of its impact. We consider the gap between “net use” and the numerical representations of such local net use justifies further exploration of potential strategies to improve LLIN use in subgroups where persisting malaria transmission clusters.

[open-access] This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Article metrics loading...

The graphs shown below represent data from March 2017
Loading full text...

Full text loading...



  1. WHO Global Malaria Programme, 2007. Insecticide-Treated Nets: A WHO Position Statement. Geneva, Switzerland: WHO. Available at: http://www.ivcc.com/sites/ivcc.mrmdev.co.uk/files/content/itnspospaperfinal.pdf. Accessed October 6, 2015. [Google Scholar]
  2. WHO, 2013. Vector Control Technical Expert Group Report to MPAC: Methods for Maintaining Coverage with Long-Lasting Insecticidal Nets (LLINs). Geneva, Switzerland: WHO. Available at: https://www.who.int/malaria/mpac/mpac_sep13_vcteg_llin_survival_report.pdf?ua=1. Accessed October 6, 2015. [Google Scholar]
  3. Roll Back Malaria Partnership to End Malaria, 2013. Malaria Indicator Survey Toolkit. Available at: https://malariasurveys.org/toolkit.cfm. Accessed October 6, 2015.
  4. Killeen GF, , 2014. Characterizing, controlling and eliminating residual malaria transmission. Malar J 13: 330. [Google Scholar]
  5. Dunn CE, Le Mare A, Makungu C, , 2011. Malaria risk behaviours, socio-cultural practices and rural livelihoods in southern Tanzania: implications for bednet usage. Soc Sci Med 72: 408417. [Google Scholar]
  6. Peeters Grietens K, 2013. Traditional nets interfere with the uptake of long-lasting insecticidal nets in the Peruvian Amazon: the relevance of net preference for achieving high coverage and use. PLoS One 8: e50294. [Google Scholar]
  7. Gryseels C, 2015. Re-imagining malaria: heterogeneity of human and mosquito behaviour in relation to residual malaria transmission in Cambodia. Malar J 14: 165. [Google Scholar]
  8. Grietens KP, Xuan XN, Ribera J, Duc TN, Bortel Wv, Ba NT, Van KP, Xuan HL, D’Alessandro U, Erhart A, , 2012. Social determinants of long lasting insecticidal hammock use among the Ra-glai ethnic minority in Vietnam: implications for forest malaria control. PLoS One 7: e29991. [Google Scholar]
  9. Monroe A, Harvey SA, Lam Y, Muhangi D, Loll D, Kabali AT, Weber R, , 2014. “People will say that I am proud”: a qualitative study of barriers to bed net use away from home in four Ugandan districts. Malar J 13: 82. [Google Scholar]
  10. Atkinson J-A, Bobogare A, Fitzgerald L, Boaz L, Appleyard B, Toaliu H, , 2009. A qualitative study on the acceptability and preference of three types of long-lasting insecticide-treated bed nets in Solomon Islands: implications for malaria elimination. Malar J 8: 119. [Google Scholar]
  11. Gore-Langton GR, 2015. Investigating the acceptability of non-mesh, long-lasting insecticidal nets amongst nomadic communities in Garissa County, Kenya using a prospective, longitudinal study design and cross-sectional household surveys. Malar J 14: 52. [Google Scholar]
  12. Binka FN, Adongo P, , 1997. Acceptability and use of insecticide impregnated bednets in northern Ghana. Trop Med Int Health 2: 499507. [Google Scholar]
  13. Gunasekaran K, Sahu SS, Vijayakumar KN, Jambulingam P, , 2009. Acceptability, willing to purchase and use long lasting insecticide treated mosquito nets in Orissa state, India. Acta Trop 112: 149155. [Google Scholar]
  14. Ingabire CM, Rulisa A, van Kempen L, Muvunyi C, Koenraadt CJM, Van Vugt M, Mutesa L, Van Den Borne B, Alaii J, , 2015. Factors impeding the acceptability and use of malaria preventive measures: implications for malaria elimination in eastern Rwanda. Malar J 14: 136. [Google Scholar]
  15. Peeters Grietens K, 2015. Characterizing types of mobility to inform differential and targeted malaria elimination strategies in northeast Cambodia. Sci Rep 5: 16837. [Google Scholar]
  16. Monroe A, Asamoah O, Lam Y, Koenker H, Psychas P, Lynch M, Ricotta E, Hornston S, Berman A, Harvey SA, , 2015. Outdoor-sleeping and other night-time activities in northern Ghana: implications for residual transmission and malaria prevention. Malar J 14: 35. [Google Scholar]
  17. Brook RH, , 2009. Assessing the appropriateness of care–its time has come. JAMA 302: 997998. [Google Scholar]
  18. Sanmartin C, 2008. Appropriateness of healthcare interventions: concepts and scoping of the published literature. Int J Technol Assess Health Care 24: 342349. [Google Scholar]
  19. Gryseels C, 2015. Factors influencing the use of topical repellents: implications for the effectiveness of malaria elimination strategies. Sci Rep 5: 16847. [Google Scholar]
  20. Sluydts V, 2014. Spatial clustering and risk factors of malaria infections in Ratanakiri Province, Cambodia. Malar J 13: 387. [Google Scholar]
  21. Heng S, Durnez L, Mao S, Siv S, Tho S, Mean V, Sluydts V, Coosemans M, , 2017. Passive case detection of malaria in Ratanakiri Province (Cambodia) to detect villages at higher risk for malaria. Malar J 16: 104. [Google Scholar]
  22. Canavati SE, Lawpoolsri S, Quintero CE, Nguon C, Ly P, Pukrittayakamee S, Sintasath D, Singhasivanon P, Grietens KP, Whittaker MA, , 2016. Village malaria worker performance key to the elimination of artemisinin-resistant malaria: a Western Cambodia health system assessment. Malar J 15: 282. [Google Scholar]
  23. Bourdier F, , 2006. The Mountain of Precious Stones. Phnom Penh, Cambodia: The Center for Khmer Studies. [Google Scholar]
  24. Bourdier F, , 1998. Health, women and environment in a marginal region of north-eastern Cambodia. GeoJournal 44: 141150. [Google Scholar]
  25. Gryseels C, 2015. High mobility and low use of malaria preventive measures among the Jarai male youth along the Cambodian-Vietnamese border. Am J Trop Med Hyg 93: 810818. [Google Scholar]
  26. Tami A, Mubyazi G, Talbert A, Mshinda H, Duchon S, Lengeler C, , 2004. Evaluation of Olyset insecticide-treated nets distributed seven years previously in Tanzania. Malar J 3: 19. [Google Scholar]
  27. Haas PM, , 2011. Introduction: epistemic communities and international policy coordination. Int Organ 46: 135. [Google Scholar]
  28. Knorr Cetina K, , 1999. Epistemic Cultures: How the Sciences Make Knowledge. Cambridge, MA: Harvard University Press. [Google Scholar]
  29. Dalglish SL, George A, Shearer JC, Bennett S, , 2018. Epistemic communities in global health and the development of child survival policy: a case study of iCCM. Health Policy Plan 30 (Suppl 2): ii12ii25. [Google Scholar]
  30. Kelly AH, Beisel U, , 2011. Neglected malarias: the frontlines and back alleys of global health. BioSocieties 6: 7187. [Google Scholar]
  31. The Global Fund: Office of the Inspector General, 2013. Investigation Report of Global Fund Grants to Cambodia Principal Recipients CNM, NCHADS and MoH and NCHADS Sub-Recipient MEDiCAM. Geneva, Switzerland: The Global Fund. Available at: https://www.theglobalfund.org/media/2774/oig_gfoig13050investigationcambodia_report_en.pdf?u=636784021740000000. Accessed October 6, 2015. [Google Scholar]
  32. Aleme A, Girma E, Fentahun N, , 2014. Willingness to pay for insecticide-treated nets in Berehet District, Amhara Region, Northern Ethiopia: implication of social marketing. Ethiop J Health Sci 24: 7584. [Google Scholar]
  33. Nathan R, Masanja H, Mshinda H, Schellenberg JA, de Savigny D, Lengeler C, Tanner M, Victora CG, , 2004. Mosquito nets and the poor: can social marketing redress inequities in access? Trop Med Int Health 9: 11211126. [Google Scholar]
  34. Grabowsky M, Nobiya T, Selanikio J, , 2007. Sustained high coverage of insecticide-treated bednets through combined catch-up and keep-up strategies. Trop Med Int Health 12: 815822. [Google Scholar]
  35. Willey BA, Paintain S, Mangham L, Armstrong J, Willey BA, , 2012. Strategies for delivering insecticide-treated nets at scale for malaria control: a systematic review. Bull World Health Organ 90: 672684. [Google Scholar]
  36. Brinkley J, , 2012. Cambodia’s Curse: The Modern History of a Troubled Land. New York, NY: Public Affairs. [Google Scholar]
  37. Cui L, 2012. Malaria in the Greater Mekong Subregion: heterogeneity and complexity. Acta Trop 121: 227239. [Google Scholar]
  38. Erhart A, Thang ND, Hung NQ, Toi le V, Hung le X, Tuy TQ, Cong le D, Speybroeck N, Coosemans M, D’Alessandro U, , 2004. Forest malaria in Vietnam: a challenge for control. Am J Trop Med Hyg 70: 110118. [Google Scholar]
  39. Erhart A, 2005. Epidemiology of forest malaria in central Vietnam: a large scale cross-sectional survey. Malar J 4: 58. [Google Scholar]
  40. Sluydts V, 2016. Efficacy of topical mosquito repellent (picaridin) plus long-lasting insecticidal nets versus long-lasting insecticidal nets alone for control of malaria: a cluster randomised controlled trial. Lancet Infect Dis 16: 11691177. [Google Scholar]
  41. Huy R, Sovannaroth S, Lek D, Chan V, Chea S, Yeang O, Bou Kheng T, Montha M, Yom Y, Theassy HC, , 2013. Cambodia Malaria Survey. Phnom Penh, Cambodia: Malaria Consortium. [Google Scholar]
  42. Koenker H, Kilian A, , 2014. Recalculating the net use gap: a multi-country comparison of ITN use versus ITN access. PLoS One 9: e97496. [Google Scholar]
  43. Koenker H, Yukich JO, , 2017. Effect of user preferences on ITN use: a review of literature and data. Malar J 16: 233. [Google Scholar]
  44. Durnez L, Mao S, Denis L, Roelants P, Sochantha T, Coosemans M, , 2013. Outdoor malaria transmission in forested villages of Cambodia. Malar J 12: 329. [Google Scholar]
  45. Peeters Grietens K, Xuan XN, Van Bortel W, Duc TN, Ribera JM, Ba Nhat T, Van KP, Le Xuan H, D’Alessandro U, Erhart A, , 2010. Low perception of malaria risk among the Ra-glai ethnic minority in south-central Vietnam: implications for forest malaria control. Malar J 9: 23. [Google Scholar]
  46. Lengeler C, Snow RW, , 1996. From efficacy to effectiveness: insecticide-treated bednets in Africa. Bull World Health Organ 74: 325332. [Google Scholar]
  47. Nordon C, Karcher H, Groenwold RHH, Ankarfeldt MZ, Pichler F, Chevrou-severac H, Rossignol M, Abbe A, Abenhaim L, GetReal Consortium; , 2016. The “efficacy-effectiveness gap”: historical background and current conceptualization. Value Health 19: 7581. [Google Scholar]
  48. Beer N, Ali AS, de Savigny D, Al-Mafazy A-WH, Ramsan M, Abass AK, Omari RS, Björkman A, Källander K, , 2010. System effectiveness of a targeted free mass distribution of long lasting insecticidal nets in Zanzibar, Tanzania. Malar J 9: 173. [Google Scholar]
  49. Killeen GF, Kihonda J, Lyimo E, Oketch FR, Kotas ME, Mathenge E, Schellenberg JA, Lengeler C, Smith TA, Drakeley CJ, , 2006. Quantifying behavioural interactions between humans and mosquitoes: evaluating the protective efficacy of insecticidal nets against malaria transmission in rural Tanzania. BMC Infect Dis 6: 161. [Google Scholar]
  50. WHO Global Malaria Programme, 2017. Achieving and Maintaining Universal Coverage with Long-Lasting Insecticidal Nets for Malaria Control. Available at: http://apps.who.int/iris/bitstream/handle/10665/259478/WHO-HTM-GMP-2017.20-eng.pdf?sequence=1. Accessed May 5 2018. [Google Scholar]
  51. Berthe S, Loll D, Faye SL, Wone I, Koenker H, Arnold B, Weber R, , 2014. “When I sleep under the net, nothing bothers me; I sleep well and I’m happy”: Senegal’s culture of net use and how inconveniences to net use do not translate to net abandonment. Malar J 13: 357. [Google Scholar]
  52. Koenker HM, Loll D, Rweyemamu D, Ali AS, , 2013. A good night’s sleep and the habit of net use: perceptions of risk and reasons for bed net use in Bukoba and Zanzibar. Malar J 12: 203. [Google Scholar]

Data & Media loading...

  • Received : 06 Sep 2018
  • Accepted : 16 Mar 2019
  • Published online : 15 Apr 2019

Most Cited This Month

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error