Evaluation of the barriers to sustained coverage and use of long-lasting insecticide-treated nets, and the effectiveness of door-to-door hang-up activities: The case of the Nord-Ubangi province, Democratic Republic of the Congo Open Access

Mushimbele, Nadine Memeh (2017)

Permanent URL: https://etd.library.emory.edu/concern/etds/9z903078k?locale=en


Background: Long-lasting insecticide treated nets (LLINs) have been proven to be effective in preventing malaria in at-risk populations. Between December 2015 and July 2016, 730,000 LLINs were distributed free-of-charge in the Nord-Ubangi province, Democratic Republic of the Congo (DRC) using the door-to-door hang-up strategy with the goal of achieving universal coverage. This study aims to evaluate the post-distribution rate of coverage of LLINs, the effectiveness of door-to-door hang-up activities on increasing household ownership and usage of LLINs, and the barriers to LLIN use. Methods: This was a mixed-methods study conducted between June and July, 2016, in three of the eleven health districts in Nord-Ubangi. The study used a multiple stage sampling technique consisting of convenience sampling and simple random sampling. Data was collected from 305 randomly-selected households across the three health districts using structured household surveys and unstructured observations. The data were analyzed using Epi Info 7.2 and SAS 9.4. Results: The proportion of households owning at least one campaign LLIN was 100% across all three health districts. However, only 48% of the campaign LLINs were found hung over sleeping spaces and 52% were not hung. 21% of observed household sleeping spaces were covered by non-campaign LLINs. This increased the percentage of LLIN coverage to 69%. The study determined that the major barriers to LLIN use include too few household LLINs to cover all sleeping spaces (33%), lack of materials for hanging LLINs (25%), lack of knowledge and assistance for hanging LLINs (13%), and sleeping spaces being used for other activities during the day (16%). LLINs surveyed were in very good condition. Of the 305 households surveyed, the proportion of LLINs hung by community health workers was 8%, while 92% were hung by members of the households. Conclusion: The mass-distribution campaign was effective at rapidly increasing LLIN ownership, but the door-to-door hang-up strategy was not effective at increasing LLIN usage. The campaign did not achieve its universal coverage goal. Mass-distribution campaigns should incorporate behavior-change communication models and other determinants of behavior into future distribution campaigns. This could limit most of the barriers to sustained LLIN usage and help increase LLIN utilization among households.

Table of Contents


Acknowledgements i

Table of Contents ii

List of Tables v

List of Figures vi

List of Acronyms vii


1.0. Introduction and Rationale 1

1.1. Problem Statement 4

1.2. Purpose Statement 6

1.3. Study Objectives 6

1.3.1. Specific Aims 7

1.4. Significance Statement 7

1.5. Definition of Terms 8


2.0. Introduction 9

2.1. Malaria Occurrence and Distribution 9

2.1.1. Malaria in the World 9

2.1.2. Malaria in Africa 13

2.1.3. Malaria in the DRC 17

2.2. Universal Coverage in Sub-Saharan Africa 20

2.2.1. Universal Coverage in the DRC 22

2.3. Effectiveness of Door-to-Door Hang-up Campaigns

In Sub-Saharan Africa 24

2.3.1. Door-to-Door Hang-up Campaigns in the DRC 26

2.4. LLIN Ownership and Usage 27

2.5. Barriers to LLIN Use in Sub-Saharan Africa 29

2.5.1. Barriers to LLIN Use in the DRC 32

2.6. Summary 33


3.0. Introduction 34

3.1. Research Design 34

3.2. Target Population 35

3.3. Indicators and Data Source 37

3.4. Sample Size procedure 42

3.4.1. Selection of Health Districts 43

3.4.2. Characteristics of Health Districts 43 Gbadolite Health District 43 Bosobolo Health District 45 Karawa Health District 47

3.4.2. Selection of Health Zones 49

3.4.3. Selection of Households 49

3.5. Data Collection and Research Instruments 50

3.5.1. Structured Survey 51

3.5.2. Unstructured Observations 51

3.6. Quality Control Measures 52

3.6.1. Validity of the Survey 52

3.6.2. Reliability of the Survey 53

3.7. Data Analysis Technique 53

3.8. Ethical Considerations 54

3.9. Limitations and Delimitations 55

3.9.1. Limitations 55

3.9.2. Delimitations 56


4.0. Introduction 57

4.1. Survey Response Rate 57

4.2. Overview of the Results 58

4.3. Indicator Findings by Health District 64

4.3.1. Household LLIN Ownership 64

4.3.2. Household LLIN Coverage 65

4.3.3. LLIN Usage Rates 67

4.3.4. Door-to-Door Hang-Up and Net Condition 70

4.3.5. Knowledge of Correct LLIN Use 71

4.4. Other Findings 75

4.5. Unstructured Observation Results 75

4.6. Summary of Findings 77


5.0. Introduction 79

5.1. Main Findings 79

5.1.1. Universal Coverage 80

5.1.2. Effectiveness of Door-to-Door Hang-Up Campaigns 81

5.1.3. LLIN Ownership and Usage 83

5.1.4. Barriers to LLIN Use 84

5.2. Limitations 86

5.3. Conclusion 87


6.0. Introduction 89

6.1. Recommendations 89

6.2. Recommendations for Further Research 90



Appendix I: Survey Questionnaires (English) 103

Appendix II: Survey Questionnaire (French) 104

Appendix III: Unstructured Observation of CHWs 105

About this Master's Thesis

Rights statement
  • Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.
  • English
Research Field
Committee Chair / Thesis Advisor
Committee Members
Partnering Agencies
Last modified

Primary PDF

Supplemental Files