Targeting strategies of antenatal balanced energy and protein supplementation in Addis Ababa, Ethiopia: study protocol for a randomized effectiveness study

BACKGROUND

Antenatal balanced energy and protein (BEP) supplements have well-documented benefits for pregnancy outcomes. However, considerable practical gaps remain in the effective and cost-effective delivery of antenatal BEP supplements at scale in low- and middle-income countries.

METHODS

A randomized effectiveness study will be conducted in two sub-cities of Addis Ababa, Ethiopia, to evaluate the effectiveness, cost-effectiveness, and implementation of different targeting strategies of antenatal BEP supplements. Pregnant women aged 18 to 49, with a gestational age of 24 weeks or less, and attending antenatal visits in one of the nine study health facilities are eligible for enrollment. In six of the health facilities, participants will be randomized to one of three study arms: control (Arm 1), targeted BEP provision based on baseline nutritional status (Arm 2), and targeted BEP supplementation based on baseline nutritional status and monthly gestational weight gain (GWG) monitoring (Arm 3). In the remaining three facilities, participants will be assigned to universal BEP provision (Arm 4). Participants in Arms 2 and 3 will receive BEP supplements if they have undernutrition at enrollment, as defined by a baseline body mass index less than 18.5 kg/m2 or mid-upper arm circumference less than 23 cm. In Arm 3, in addition to targeting based on baseline undernutrition, regular weight measurements will be used to identify insufficient GWG and inform the initiation of additional BEP supplements. Participants in Arm 4 will receive BEP supplements until the end of pregnancy, regardless of baseline nutritional status or GWG. All participants will receive standard antenatal care, including iron and folic acid supplementation. A total of 5400 pregnant women will be enrolled, with 1350 participants in each arm. Participants will be followed up monthly during their visits to the antenatal facilities until delivery. Maternal and infant health status will be evaluated within 72 h after delivery and at 6 weeks postpartum. The effectiveness and cost-effectiveness of the different BEP targeting strategies in preventing adverse pregnancy outcomes will be compared across arms. Qualitative data will be analyzed to assess the feasibility, acceptability, and implementation of different supplementation strategies.

DISCUSSION

This study will inform global recommendations and operational guidelines for the effective and cost-effective delivery of antenatal BEP supplements. The targeted approaches have the potential for broader scale-up in Ethiopia and other low-resource settings with a high burden of undernutrition among pregnant women.

TRIAL REGISTRATION

ClinicalTrials.gov registration number: NCT06125860. Registered November 9, 2023.

The economic burden of hemodialysis and associated factors of among patients in private and public health facilities: a cross-sectional study in Addis Ababa, Ethiopia

INTRODUCTION

The treatment of kidney disease, including hemodialysis, poses challenges in healthcare and finances. Despite limited data on hemodialysis costs and determinants in Ethiopia, existing literature indicates a paucity of evidence regarding the economic burden of hemodialysis. This study aims to evaluate the direct and indirect costs of hemodialysis among end-stage renal disease (ESRD) patients, alongside associated factors, among selected governmental and private institutions in Addis Ababa, Ethiopia.

METHODS

An institutional-based cross-sectional study using a simple random sampling technique was conducted from September 10 to November 1, 2021. One hundred twenty-eight patients participated in the study. Data was collected using an interviewer-administered questionnaire. The analysis used proportion and frequency measures of central tendency and linear regression measures. Both simple and multiple linear regression models were used to assess associated factors. The final model used a P value < 0.05 at 95% confidence interval (CI) was used to determine significance.

RESULT

The mean cost of hemodialysis in a representative sample of selected hospitals in Addis Ababa was 7,739.17 $ ±2,833.51 $, with direct medical cost contributing 72.9% of the total cost. Furthermore, the institution type (private or public) and duration on hemodialysis were associated with an increased cost of hemodialysis.

CONCLUSION

Our findings underline the necessity for policymakers, program administrators, and healthcare institution executives to prioritize this group, recognizing the substantial load they bear and extending these services in government facilities to a broader patient population.

Perception of affordable diet is associated with pre-school children's diet diversity in Addis Ababa, Ethiopia: the EAT Addis survey

BACKGROUND

Despite improvements in food access and nutrition security over the last few decades, malnutrition remains a major public health problem. One of the significant contributors to these problems is affordability of nutritious food. This study aimed to examine the association between perceived food affordability and pre-school children's diet diversity in Addis Ababa, Ethiopia.

METHODS

Cross-sectional data from 2017 to 18 were used for the analysis. A 24-hour dietary recall assessment was done to assess children's dietary diversity (DD). We used a modified operational definition of affordability indicator called perceived affordability of dietary diversity (afford-DD) to evaluate the impact of the food environment in terms of affordability at the household level. A sample (n 4,898) of children aged 6-59 months representative of households in Addis Ababa was randomly selected using a multistage sampling procedure including all districts in the city. Mixed-effects linear regression models were used to assess the association between children's DD and afford-DD.

RESULTS

The survey revealed that the mean (standard deviation [SD]) of children's DD was 3.9 [± 1.4] while the mean [SD] of afford-DD was 4.6 [± 2.1]. Overall, 59.8% of children met the minimum dietary diversity (≥ 4 food groups). White roots and tubers were the most commonly consumed food groups regardless of their affordability. Considerable variations were observed between households that reported the food item affordable and not affordable in consumption of Vitamin A rich vegetables and fruits, meat and fish, egg, and dairy. The children's DD was positively associated with afford-DD after adjusting for maternal education, household wealth status and other relevant confounding. Higher maternal education modified the association between affordability and children's diet diversity.

CONCLUSIONS

This study suggests higher perceived food affordability was associated with better diet diversity in children. A higher level of maternal education had the potential to mitigate affordability challenges in meeting the children's dietary diversity needs. Our study emphasizes the need for inclusive food programs and nutrition interventions addressing social differences, intensifying efforts to make nutrient-rich diets affordable for the less privileged, and highlights the potential benefits of targeting maternal education in addressing child dietary diversity.

Durability of long-lasting insecticidal nets (LLINs) in Ethiopia

BACKGROUND

The functional survival time of long-lasting insecticidal nets (LLINs), which varies across different field contexts, is critical for the successful prevention of malaria transmission. However, there is limited data on LLIN durability in field settings in Ethiopia.

METHODS

A three-year longitudinal study was conducted to monitor attrition, physical integrity, and bio-efficacy and residual chemical concentration of LLINs in four regions in Ethiopia. World Health Organization (WHO) guidelines were used to determine sample size, measure physical integrity, and calculate attrition rates, and functional survival time. Yearly bio-efficacy testing was done on randomly selected LLINs. An excel tool developed by vector works project was used to calculate the median functional survival time of the LLINs. Predictors of functional survival were identified by fitting binary and multivariate cox proportional hazards model.

RESULTS

A total of 3,396 LLINs were included in the analysis. A total of 3,396 LLINs were included in the analysis. By the end of 36 months, the proportion of LLINs functionally surviving was 12.9% [95% confidence interval (CI) 10.5, 15.6], the rates of attrition due to physical damage and repurposing were 48.8% [95% confidence interval (CI) 45.0, 52.6] and 13.8% [95% confidence interval (CI) 11.6, 14.6], respectively. The estimated median functional survival time was 19 months (95%CI 17, 21). Factors associated with shorter functional survival time include being in a low malaria transmission setting [Adjusted Hazards Ratio (AHR) (95%CI) 1.77 (1.22, 2.55)], rural locations [AHR (95%CI) 1.83 (1.17, 2.84)], and in a room where cooking occurs [AHR (95%CI) 1.28 (1.05, 1.55)]. Bioassay tests revealed that 95.3% (95%CI 86.4, 98.5) of the LLINs met the WHO criteria of bio-efficacy after 24 months of distribution.

CONCLUSION

The LLIN survival time was shorter than the expected three years due to high attrition rates and rapid loss of physical integrity. National malaria programmes may consider, procuring more durable LLINs, educating communities on how to prevent damage of LLINs, and revising the current three-year LLIN distribution schedule to ensure sufficient protection is provided by LLINs against malaria transmission. While this paper contributes to the understanding of determinants impacting functional survival, further research is needed to understand factors for the rapid attrition rates and loss of physical integrity of LLINs in field settings.

Key correlates of exclusive breastfeeding at three timepoints: Evidence from Ethiopia

Aim

To compare factors associated with exclusive breastfeeding (EBF) within 1 h of birth, within 3 days, and within the first 6 months post-birth.

Methods

We used multivariate logistic regression models and data from "The Alive and Thrive Phase 2 Amhara Baseline Survey 2015" from Ethiopia (N = 3113).

Results

Giving colostrum was strongly associated with EBF at all three time points, controlling for multiple confounders. Putting the baby to the breast before cleaning the baby and before cleaning the mother was significantly associated with EBF within 1 h and for the first 3 days. EBF within an hour of birth was more likely for girl babies than boy babies. Having a healthcare professional check whether the baby was sucking well was significantly associated with EBF 3 days post-birth.

Conclusions

The World Health Organization recommends breastfeeding within 1 h of birth and exclusively thereafter for 6 months, which can improve health outcomes for infants and children. In Ethiopia, many factors influence breastfeeding practices, but little is known about how these factors differ at various key timepoints in the 6 months after birth. Our study provides important information on correlates of EBF at three timepoints and shows that factors that are significantly correlated with EBF vary over time. Future research should assess the potential causal links among statistically significant associations between EBF and risk factors at various times between birth and 6 months of age. Ultimately, these findings have the potential to inform areas of intervention related to promoting EBF.

Evaluation of the effect of targeted Mass Drug Administration and Reactive Case Detection on malaria transmission and elimination in Eastern Hararghe zone, Oromia, Ethiopia: a cluster randomized control trial

Background

Reactive and proactive case detection measures are widely implemented by national malaria elimination programs globally. Ethiopia decided to include Reactive Case Detection (RCD) and targeted Mass Drug Administration (tMDA) approaches as part of their elimination strategy along with rigorous evaluation. The purpose of this study is to compare the impact of RCD and tMDA on malaria elimination over the 2-year study period, by looking at the annual parasite incidence before and after the intervention.

Methods

The study will be conducted in the East Hararghe zone of Ethiopia. Malaria transmission in the area is low to moderate. This study will deploy a community-based, three-arm, cluster-randomized control trial implemented over 2 years. Forty-eight clusters (16 clusters per arm) will be selected based on the annual number of confirmed malaria cases seen in the cluster. All clusters will receive the current standard of care in terms of malaria elimination interventions provided by the national malaria control program. In addition, following the identification of malaria parasite infection, individuals who reside within a 100-m radius of the index case will receive a diagnosis for malaria and treatment if positive in the RCD arm or presumptive treatment in the tMDA arm. The primary effectiveness endpoint will be measured at baseline and endline for each intervention arm and compared to the control arm using a difference in difference approach.

Discussion

This randomized controlled trial will provide evidence of the impact of the proposed intervention approaches for malaria elimination.

Trial registration

ClinicalTrials.gov NCT04241705. Registration date: January 27, 2020.

The effect of long-lasting insecticidal nets (LLINs) physical integrity on utilization

BACKGROUND

In Ethiopia, despite improvements in coverage and access, utilization of long-lasting insecticidal nets (LLINs) remains a challenge. Different household-level factors have been identified as associated with LLIN use. However, the contribution of LLIN physical integrity to their utilization is not well investigated and documented. This study aimed to assess the association between the physical integrity of LLINs and their use.

METHODS

This study employed a nested case-control design using secondary data from the Ethiopian LLIN durability monitoring study conducted from May 2015 to June 2018. LLINs not used the night before the survey were identified as cases, while those used the previous night were categorized as controls. The physical integrity of LLINs was classified as no holes, good, acceptable, and torn using the proportionate hole index (pHI). A Generalized Estimating Equation (GEE) model was used to assess and quantify the association between LLIN physical integrity and use. The model specifications included binomial probabilistic distribution, logit link, exchangeable correlation matrix structure, and robust standard errors. The factors included in the model were selected first by fitting binary regression, and then by including all factors that showed statistical significance at P-value less than 0.25 and conceptually relevant variables into the multivariate regression model.

RESULTS

A total of 5277 observations fulfilled the inclusion criteria. Out of these 1767 observations were cases while the remaining 3510 were controls. LLINs that were in torn physical condition had higher odds (AOR [95% CI] = 1.76 [1.41, 2.19]) of not being used compared to LLINs with no holes. Other factors that showed significant association included the age of the LLIN, sleeping place type, washing status of LLINs, perceptions towards net care and repair, LLIN to people ratio, economic status, and study site.

CONCLUSION AND RECOMMENDATION

LLINs that have some level of physical damage have a relatively higher likelihood of not being used. Community members need to be educated about proper care and prevention of LLIN damage to delay the development of holes as long as possible and use available LLINs regularly.

Baseline malaria prevalence at the targeted pre-elimination districts in Ethiopia

Background

Encouraged by the previous success in malaria control and prevention strategies, the Ethiopian ministry of health launched malaria elimination with a stepwise approach by primarily targeting the low-transmission Districts and their adjacent areas/zones in order to shrink the country’s malaria map progressively. Hence, this community survey was conducted to establish baseline malaria information at the preliminary phase of elimination at targeted settings.

Methods

A community-based cross-sectional survey was conducted at 20 malaria-elimination targeted Districts selected from five Regional states and one city administration in Ethiopia. The GPS-enabled smartphones programmed with Open Data Kit were used to enumerate 9326 study households and collect data from 29,993 residents. CareStart™ Malaria PAN (pLDH) Rapid Diagnostic Tests (RDTs) were used for blood testing at the field level. Armpit digital thermometers were used to measure axillary temperature.

Result

Overall malaria prevalence by RDTs was 1.17% (339/28973). The prevalence at District levels ranged from 0.0 to 4.7%. The proportion of symptomatic cases (axillary temperature > 37.5^oc) in the survey was 9.2% (2760/29993). Among the 2510 symptomatic individuals tested with RDTs, only 3.35% (84/2510) were malaria positive. The 75.2% (255/339) of all malaria positives were asymptomatic. Of the total asymptomatic malaria cases, 10.2% (26/255) were under-five children and 89.8% (229/255) were above 5 years of age.

Conclusion

The study shows a decrease in malaria prevalence compared to the reports of previous malaria indicator surveys in the country. The finding can be used as a baseline for measuring the achievement of ongoing malaria elimination efforts. Particularly, the high prevalence of asymptomatic individuals (0.88%) in these transmission settings indicates there may be sustaining hidden transmission. Therefore, active case detection with more sensitive diagnostic techniques is suggested to know more real magnitude of residual malaria in the elimination-targeted areas.

The Social Stratification of Availability, Affordability, and Consumption of Food in Families with Preschoolers in Addis Ababa; The EAT Addis Study in Ethiopia

The aim of this study was to understand the quality of diet being consumed among families in Addis Ababa, and to what extent social stratification and perceptions of availability and affordability affect healthy food consumption. Data were collected from 5467 households in a face-to-face interview with mothers/caretakers and analyzed using mixed effect logistic regression models. All family food groups, except fish were perceived to be available by more than 90% of the participants. The food groups cereals/nuts/seeds, other vegetables, and legumes were considered highly affordable (80%) and were the most consumed (>75%). Households with the least educated mothers and those in the lowest wealth quintile had the lowest perception of affordability and also consumption. Consumption of foods rich in micronutrients and animal sources were significantly higher among households with higher perceived affordability, the highest wealth quintile, and with mothers who had better education. Households in Addis Ababa were generally seen to have a monotonous diet, despite the high perceived availability of different food groups within the food environment. There is a considerable difference in consumption of nutrient-rich foods across social strata, hence the cities food policies need to account for social differences in order to improve the nutritional status of the community.

A Chicken Production Intervention and Additional Nutrition Behavior Change Component Increased Child Growth in Ethiopia: A Cluster-Randomized Trial

BACKGROUND

Chicken production in the context of nutrition-sensitive agriculture may benefit child nutrition in low-income settings.

OBJECTIVES

This study evaluated effects of 1) a chicken production intervention [African Chicken Genetic Gains (ACGG)], and 2) the ACGG intervention with nutrition-sensitive behavior change communication (BCC) [ACGG + Agriculture to Nutrition (ATONU)], on child nutrition and health outcomes and hypothesized intermediaries.

METHODS

Forty ACGG villages received 25 genetically improved chickens and basic husbandry guidance; of these, 20 ACGG + ATONU villages in addition received a nutrition-sensitive behavior change and homegardening intervention; 20 control clusters received no intervention. We assessed effects of the interventions on height-for-age z scores (HAZ), weight-for-age z scores (WAZ), and weight-for-height z scores (WHZ) at 9 (midline) and 18 mo (endline) through unadjusted and adjusted ordinary least squares (OLS) regressions. We examined the interventions' effects on hypothesized intermediaries including egg production and consumption, dietary diversity, women's empowerment, income, child morbidities, anemia, and chicken management practices through OLS and log binomial models.

RESULTS

Data included 829 children aged 0-36 mo at baseline. ACGG + ATONU children had higher midline HAZ [mean difference (MD): 0.28; 95% CI: 0.02, 0.54] than controls. The ACGG group had higher HAZ (MD: 0.28; 95% CI: 0.05, 0.50) and higher WAZ (MD: 0.18; 95% CI: 0.01, 0.36) at endline than controls; after adjusting for potential baseline imbalance, effects were similar but not statistically significant. At endline, differences in ACGG + ATONU children's HAZ and WAZ compared with controls were similar in magnitude to those of ACGG, but not statistically significant. There were no differences in anthropometry between the intervention groups. ACGG + ATONU children had higher dietary diversity and egg consumption than ACGG children at endline. Both interventions showed improvements in chicken management practices. The interventions did not increase anemia, diarrhea, fever, or vomiting, and the ACGG + ATONU group at midline showed reduced risk of fever.

CONCLUSIONS

A chicken production intervention with or without nutrition-sensitive BCC may have benefited child nutrition and did not increase morbidity.This trial was registered at clinicaltrials.gov as NCT03152227.

Men's nutrition knowledge is important for women's and children's nutrition in Ethiopia

In an effort to address undernutrition among women and children in rural areas of low‐income countries, nutrition‐sensitive agriculture (NSA) and behaviour change communication (BCC) projects heavily focus on women as an entry point to effect nutritional outcomes. There is limited evidence on the role of men's contribution in improving household diets. In this Agriculture to Nutrition trial (Clinicaltrials.gov identifier: NCT03152227), we explored associations between men's and women's nutritional knowledge on households', children's and women's dietary diversity. At the midline evaluation conducted in July 2017, FAO's nutrition knowledge questionnaire was administered to male and female partners in 1396 households. There was a high degree of agreement (88%) on knowledge about exclusive breastfeeding between parents; however, only 56–66% of the households had agreement when comparing knowledge of dietary sources of vitamin A or iron. Factor analysis of knowledge dimensions resulted in identifying two domains, namely, ‘dietary’ and ‘vitamin’ knowledge. Dietary knowledge had a larger effect on women's and children's dietary diversities than vitamin knowledge. Men's dietary knowledge had strong positive associations with households' dietary diversity scores (0.24, P value = 0.001), children's dietary diversity (0.19, P value = 0.008) and women's dietary diversity (0.18, P value < 0.001). Distance to markets and men's education levels modified the effects of nutrition knowledge on dietary diversity. While previous NSA and BCC interventions predominantly focused on uptake among women, there is a large gap and strong potential for men’s engagement in improving household nutrition. Interventions that expand the role of men in NSA may synergistically improve household nutrition outcomes.

Adolescent Girls' Agency Significantly Correlates With Favorable Social Norms in Ethiopia-Implications for Improving Sexual and Reproductive Health of Young Adolescents

PURPOSE

This study investigates the relationship between adolescent girls' agency and social norms regarding early marriage, girls' education, and nutrition in West Hararghe, Ethiopia.

METHODS

We conducted a cross-sectional study involving adolescent girls aged between 13 and 17 years in 2016. A two-stage cluster sampling procedure was followed to identify eligible respondents at the household level. A total of 114 clusters in four districts and 30 households from each cluster were randomly selected. Data were collected using a structured and pretested questionnaire. The agency composite score was measured based on 21 previously validated items. Descriptive and injunctive norm composite scores regarding education, marriage, and nutrition were constructed based on context-relevant items. The weighted mean and standard errors were calculated for the agency and social norms composite scores. The relationship between girls' agency and descriptive and injunctive norms were examined using a multivariable linear regression model that accounted for a complex sample survey design.

RESULTS

A total of 3,186 adolescent girls participated in this study. The multivariable linear regression analysis revealed that adolescent girls' agency score significantly and favorably associated with education (β = .19, p < .001), marriage (β = .13, p < .01), and nutrition (β = .20, p < .01) descriptive norms after adjusting for individual and household characteristics. Similarly, adolescent girls' agency was significantly and favorably associated with marriage (β = .21, p < .001) injunctive norms; however, positive injunctive norms around education (β = .09, p > .05) and nutrition (β = .12, p > .05) did not have a statistically significant association with girls' agency. The domains of agency scale related to the belief in women's health rights related to contraception use and the belief in women's right to refuse sex showed poor prosocial views.

CONCLUSIONS

Favorable descriptive and injunctive norms around marriage were significantly associated with greater adolescent girls' agency, which indicates the need to incorporate interventions that address social norms in efforts aimed to enhance adolescent girls' sexual and reproductive health status. Furthermore, attention should be given to monitor which domain of agency is improved by the interventions.

Etiology of Chronic Liver Disease in Ethiopia: A Case Control Study with Special Reference to Viral Hepatitis and Alcohol

INTRODUCTION

Chronic diseases of the liver are a global health problem with high morbidity and mortality. Viral hepatitis is the predominant cause for liver disease in low and middle-income countries. Viral hepatitis is also frequent in high-income countries but mainly as a complication to drug abuse or iatrogenic to treatment. In high-income countries non-fatty-liver-disease and complications to alcohol consumption are the most frequent etiology of liver disease. Viral hepatitis B and C is prevalent in Ethiopia but there are only few studies done in relation to chronic liver disease and a relationship between the increasing alcohol consumption and chronic liver disease.

OBJECTIVE

A The aim of the study was to assess the association between chronic liver disease in Ethiopia and infection with viral hepatitis and possible relation to alcohol consumption.

METHODS AND MATERIAL

An unmatched case control study was conducted in Addis Ababa. Cases were chronic liver disease patients (n = 812) and controls were patients without liver disease (n = 798). Data were collected from the records of patients treated at a specialized clinic of Gastrsoenterology and Hepatology in Addis Ababa from 1^st January 2013 - 31^st, December 2013.

RESULTS

The odds of having hepatitis infection among chronic liver disease was AOR = 100.96, (95%CI: 62.15 - 164.02) for HBV and AOR = 59.2, (95%CI: 27.23 - 130.9) for HCV. Consumption of alcohol was associated with chronic liver disease (OR: 8.23 95%CI: 3.76 - 12.70). Liver enzymes were elevated significantly in patients with hepatitis and alcohol consumption compared to patients without alcohol consumption.

CONCLUSION

Viral hepatitis infections are strongly associated with chronic liver disease. Prevention of viral hepatitis infections and control of alcohol consumption need to be strengthened in order to reduce the burden of chronic liver disease in Ethiopia.

Knowledge and perception towards net care and repair practice in Ethiopia

BACKGROUND

Long-lasting insecticidal nets (LLINs) are a key malaria control intervention. Although LLINs are presumed to be effective for 3 years under field or programmatic conditions, net care and repair approaches by users influence the physical and chemical durability. Understanding how knowledge, perception and practices influence net care and repair practices could guide the development of targeted behavioural change communication interventions related to net care and repair in Ethiopia and elsewhere.

METHODS

This population-based, household survey was conducted in four regions of Ethiopia [Amhara, Oromia, Tigray, Southern Nations Nationalities Peoples Region (SNNPR)] in June 2015. A total of 1839 households were selected using multi-stage sampling procedures. The household respondents were the heads of households. A questionnaire was administered and the data were captured electronically. STATA software version 12 was used to analyse the data. Survey commands were used to account for the multi-stage sampling approach. Household descriptive statistics related to characteristics and levels of knowledge and perception on net care and repair are presented. Ordinal logistic regression was used to identify factors associated with net care and repair perceptions.

RESULTS

Less than a quarter of the respondents (22.3%: 95% CI 20.4-24.3%) reported adequate knowledge of net care and repair; 24.6% (95% CI 22.7-26.5%) of the respondents reported receiving information on net care and repair in the previous 6 months. Thirty-five per cent of the respondents (35.1%: 95% CI 32.9-37.4%) reported positive perceptions towards net care and repair. Respondents with adequate knowledge on net care and repair (AOR 1.58: 95% CI 1.2-2.02), and those who discussed net care and repair with their family (AOR 1.47: 95% CI 1.14-1.89) had higher odds of having positive perceptions towards net care and repair.

CONCLUSIONS

The low level of reported knowledge on net care and repair, as well as the low level of reported positive perception towards net repair need to be addressed. Targeted behavioural change communication campaigns could be used to target specific groups; increased net care and repair would lead to longer lasting nets.