title: What happens to lost nets: a multi-country analysis of reasons for LLIN attrition using 14 household surveys in four countries.
abstract: BACKGROUND
  While significant focus has been given to net distribution, little is known about what is done with nets that leave a household, either to be used by others or when they are discarded. To better understand the magnitude of sharing LLIN between households and patterns of discarding LLIN, the present study pools data from 14 post-campaign surveys to draw larger conclusions about the fate of nets that leave households.
  
  
  METHODS
  Data from 14 sub-national post-campaign surveys conducted in Ghana, Senegal, Nigeria (10 states), and Uganda between 2009 and 2012 were pooled. Survey design and data collection methods were similar across surveys. The timing of surveys ranged from 2-16 months following their respective mass LLIN distributions.
  
  
  RESULTS
  Among the 14 surveys a total of 14,196 households reported owning 25,447 nets of any kind, of which 23,955 (94%) were LLINs. In addition, a total of 4,102 nets were reported to have left the households in the sample: 63% were discarded, and 34% were given away. Only 255 of the discarded nets were reported used for other purposes, representing less than 1% of the total sample of nets. The majority (62.5%) of nets given away were given to or taken by relatives, while 31.1% were given to non-relatives. Campaign nets were almost six times (OR 5.95, 4.25-8.32, p < 0.0001) more likely to be given away than non-campaign nets lost during the same period. Nets were primarily given away within the first few months after distribution. The overall rate of net redistribution was 5% of all nets.
  
  
  CONCLUSIONS
  Intra-household re-allocation of nets does occur, but was sensitive to current household net ownership and the time elapsed since mass distribution. These factors can be addressed programmatically to further facilitate reallocation within a given community. Secondly, the overwhelming majority of nets were used for malaria prevention. Of the repurposed nets (<1% overall), the majority were already considered too torn, indicating they had already served out their useful life for malaria prevention. National programmes and donor agencies should remain confident that overall, their investments in LLIN are being appropriately used.
authors.affiliation: Johns Hopkins Bloomberg School of Public Health Center for Communication Programs, Baltimore, MD, USA. hkoenker@jhu.edu.
authors.forename: Hannah
authors.initials: H
authors.lastname: Koenker
authors.forename: Albert
authors.initials: A
authors.lastname: Kilian
authors.forename: Celine
authors.initials: C
authors.lastname: Zegers de Beyl
authors.forename: Emmanuel O
authors.initials: EO
authors.lastname: Onyefunafoa
authors.forename: Richmond A
authors.initials: RA
authors.lastname: Selby
authors.forename: Tarekegn
authors.initials: T
authors.lastname: Abeku
authors.forename: Megan
authors.initials: M
authors.lastname: Fotheringham
authors.forename: Matthew
authors.initials: M
authors.lastname: Lynch
mesh_terms: D017954:Africa South of the Sahara; D003430:Cross-Sectional Studies; D005191:Family Characteristics; D006801:Humans; D057148:Insecticide-Treated Bednets / Q000706:statistics & numerical data*; D008288:Malaria / Q000517:prevention & control; D009032:Mosquito Control / Q000379:methods; D010067:Ownership / Q000706:statistics & numerical data*