Long-term retention and positive deviant practices in Uganda's community-based distribution program

Sustaining Consistent Net Use Through Holistic Benefits and Community Engagement

In Uganda’s mid-western region, the long-term retention and consistent use of long-lasting insecticidal nets (LLINs) distributed through a universal coverage campaign (UCC) has emerged as a complex yet intriguing challenge. Drawing insights from a multi-pronged qualitative study, this article explores the diverse factors driving positive deviant behaviors around LLIN use over time, offering valuable lessons for community-based health programs.

Understanding the Nuances of Long-Term Net Use

Malaria remains a persistent public health threat in many parts of Uganda, underscoring the critical importance of effective vector control interventions like LLINs. While initial post-distribution surveys in the study region showed promising increases in net ownership and use, these gains often waned over the subsequent years. To unpack this trend, the research team employed a triangulated qualitative approach, incorporating in-depth interviews, most significant change (MSC) analysis, and positive deviance identification.

Previous Experience and Perceived Benefits: Key Drivers of Consistent Use

A key finding emerging across the different analysis methods was the pivotal role of prior experience with net use. Respondents who had utilized nets before the UCC were far more likely to maintain consistent use over time, having already come to appreciate the diverse benefits of this protective measure. As one female caregiver from Kayanja village shared:

“Everyone in this family has a net and they all sleep under these nets because even before the government nets came, we had nets for everyone in the family so there has been no change.”

Beyond malaria prevention, respondents highlighted a range of additional advantages to net use, from improved overall health and better sleep quality to economic savings from reduced healthcare expenditures. As a female respondent from Kidoma village explained:

“The mosquitoes and insects which used to bite us or fall on us while sleeping, these days I don’t see them … so we sleep comfortably. We have peace now because the skins of my children are healthier and no longer have scars of mosquito bites. …sleeping under nets has increased my time to go to my gardens and do my domestic work without being tired and stressed.”

Narratives from the MSC stories further reinforced these diverse benefits, with themes of “fewer malaria cases,” “better overall health,” and “money savings” emerging as the most commonly cited positive changes. Respondents who placed high value on these multifaceted advantages were the most likely to exhibit positive deviant behaviors, adapting sleeping arrangements, encouraging others, and actively maintaining their nets.

Household Dynamics and Community Support: Mutually Reinforcing Influences

The study also underscored the crucial role of household decision-makers in shaping net use habits. Household heads and caregivers who enthusiastically promoted net use, even going so far as to physically assist with hanging and properly using the nets, were more successful in fostering consistent use among all family members. As one female respondent noted:

“Some children sleep carelessly, others sleep and kick these nets while sleeping and so as a parent I am forced to frequently wake up at night to check whether they are still sleeping in the nets and if not I have to cover them properly.”

Beyond the household, community-level support and encouragement also emerged as a key driver. Village leaders, community health workers, and even religious authorities were cited as important influencers, actively promoting the benefits of net use and providing hands-on assistance. As one male respondent from Nsanje village shared:

“There are people on landing sites who use nets for fishing. Some people sell nets in order to get some money while other people use nets to guard their crops from animals and other pests. People say that since these nets are treated, they are capable of chasing away animals.”

Interestingly, while a few isolated instances of net misuse or discouragement were reported, the overall community climate appeared to reinforce positive net use behaviors, with social support playing a crucial role in sustaining consistent utilization.

Navigating Practical Challenges: Flexibility and Adaptability as Key

The study also highlighted several practical challenges that threatened consistent net use, including issues with net condition, sleeping arrangements, and household size. However, positive deviant households demonstrated a remarkable ability to adapt and overcome these obstacles. For example, respondents described adjusting sleeping spaces to ensure all family members could be covered, or repairing damaged nets to prolong their usability.

As one female respondent from Bugana village explained:

“I no longer use my net because it got holes and many mosquitoes started entering in it and I decided to remove it completely from my bed. …It is my grandchild who burnt many holes into my net. He was playing with a matchbox…it was hard for me to repair. That is when I decided to remove it.”

In contrast, households that simply abandoned net use when confronted with similar challenges were far less likely to exhibit the problem-solving mindset of positive deviants. This adaptive capacity, combined with the holistic appreciation of net benefits, emerged as a powerful driver of long-term, consistent utilization.

Implications for Community-Based Programming

The insights gleaned from this multi-faceted study offer valuable lessons for community-based health initiatives seeking to promote the long-term, consistent use of preventive interventions like LLINs. Several key takeaways stand out:

Emphasize the Broader Benefits of Net Use: While malaria prevention remains a core motivation, future behavior change campaigns should also highlight the diverse social, economic, and lifestyle advantages of net use. Tapping into these non-health benefits can foster a deeper, more enduring appreciation for this protective measure.
Empower Household Decision-Makers: Recognizing the influential role of household heads and caregivers, programs should intentionally engage these key stakeholders, equipping them with the knowledge, skills, and support to champion consistent net use within their families and communities.
Leverage Community-Level Influencers: Partnering with trusted community leaders, health workers, and social networks can amplify pro-net use messaging and bolster local social norms. Identifying and empowering positive deviant households to serve as peer advocates can also catalyze broader behavior change.
Promote Adaptive Problem-Solving: Anticipating practical challenges to consistent net use, programs should encourage and enable households to develop flexible, context-appropriate solutions. This may include facilitating access to net repair materials, exploring alternative hanging methods, or supporting the transition to new net procurement strategies.
Adopt a Holistic Monitoring Approach: The use of triangulated qualitative methodologies, as demonstrated in this study, can provide rich, nuanced insights into the complex drivers of long-term intervention adoption. Coupling these techniques with quantitative assessments can help programs better understand and address the multifaceted factors shaping consistent net use over time.

By embracing these principles, community-based programs can harness the power of positive deviance and forge a path toward sustained, equitable vector control outcomes. As the fight against malaria continues, leveraging the wisdom and resilience within Ugandan communities will be crucial to maintaining the hard-won gains of life-saving LLIN interventions.

Fostering a Culture of Consistent Net Use: Lessons from Uganda’s Positive Deviants

Unpacking the Factors Driving Long-Term LLIN Retention

The distribution of long-lasting insecticidal nets (LLINs) through universal coverage campaigns has emerged as a cornerstone of malaria prevention efforts across sub-Saharan Africa, including in Uganda. However, ensuring the consistent, long-term use of these vital tools has proven to be a complex challenge, as evidenced by declining net ownership and utilization rates observed in Uganda’s mid-western region in the years following a major LLIN distribution campaign.

To better understand the factors shaping this trend, a multi-faceted qualitative study was undertaken, incorporating in-depth interviews, most significant change (MSC) analysis, and positive deviance identification. The findings offer valuable insights into the diverse drivers of sustained LLIN use, underscoring the importance of holistic benefits, adaptive problem-solving, and community-level engagement.

Previous Experience and Perceived Value: A Powerful Combination

A key driver of consistent net use over time was the prior experience of households with this preventive measure. Respondents who had utilized nets before the universal coverage campaign (UCC) distribution were far more likely to maintain regular use, having already come to appreciate the wide-ranging benefits of sleeping under an LLIN.

As one female caregiver from Kayanja village explained:

“Everyone in this family has a net and they all sleep under these nets because even before the government nets came, we had nets for everyone in the family so there has been no change.”

Beyond the well-established protection against malaria, respondents highlighted a host of additional advantages to net use, from improved overall health and better sleep quality to economic savings from reduced healthcare expenditures. As a female respondent from Kidoma village shared:

The in-depth interviews, combined with the most significant change (MSC) analysis, further reinforced these diverse benefits, with themes of “fewer malaria cases,” “better overall health,” and “money savings” emerging as the most commonly cited positive changes. Respondents who placed high value on these multifaceted advantages were the most likely to exhibit positive deviant behaviors, actively maintaining their nets and adapting sleeping arrangements to ensure consistent use.

The Crucial Role of Household Dynamics and Community Support

The study also underscored the pivotal influence of household decision-makers in shaping net use habits. Household heads and caregivers who enthusiastically promoted net use, even going so far as to physically assist with hanging and properly using the nets, were more successful in fostering consistent use among all family members. As one female respondent noted:

Adapting to Practical Challenges: The Mark of Positive Deviants