Community Compliance and Usage of Insecticide-Treated Nets (ITNs) for Malaria Prevention in the Upper River Region of The Gambia

Abstract

Background: Insecticide-treated nets (ITNs) are an important malaria prevention measure, but household ownership does not always translate into consistent use. Understanding community compliance and barriers to ITN utilization is essential for effective malaria control. This study assessed ITN utilization usage patterns and community compliance in the Upper River Region (URR) of The Gambia to better understand the gap between possessing a net and using it correctly. Methods: A community-based study was conducted across seven districts in the URR: Sandu, Jimara, Wulli East, Wulli West, Basse (Fulladu East), Tumana, and Kantora. Data were collected from 1,000 households through interviewer-administered questionnaires and direct environmental observations. The Community Compliance Index (CCI) framework was used to assess nightly ITN use, knowledge of ITN benefits, barriers to use, and the physical condition and hanging of nets. Results:  ITN ownership was high, with 94.2% of respondents reporting sufficient nets for household members, while 78.5% reported sleeping under a net every night. Knowledge of ITN benefits was high, but consistent use was affected by nighttime heat, overcrowded sleeping areas, and inadequate net maintenance. Direct observations showed that 68.3% of nets were properly hanging over sleeping areas, indicating a gap between reported use and observed readiness for use. Conclusion: Despite high ITN ownership and awareness, environmental discomfort and household structural constraints remain important barriers to consistent utilization in the URR. Malaria control programs should complement ITN distribution with behavior-change interventions addressing proper net hanging, maintenance, and heat-related discomfort.