OBJECTIVE To evaluate the use of insecticide-treated bednets and the effectiveness of social marketing for their distribution.
METHODS Systematic cluster sample survey of 1080 households in 36 census enumeration areas across Blantyre district, Malawi, in February 2000.
RESULTS A total of 672 households had one or more children under 5. Bednet ownership was low (20.5% of households) overall, and significantly lower in rural areas than urban areas (6.4 vs. 29.8%, P=0.001). Only 3.3% of rural children under 5 had slept under a net the previous night, compared with 24.0% of urban children (P < 0.001). When asked why they did not own a net, nearly all (94.9%) caretakers in households without nets stated they had no money to buy them. In multivariate statistical models that controlled for the influence of house structure, urban vs. rural location, gender of the head of household, and the primary caretaker's education, rural children under 5 in households without nets experienced a statistically significant higher prevalence of malaria parasitaemia [RR (risk ratio) 4.9, 95% CI (confidence interval) 2.3–10.5] than children in households with at least one bednet. This was also true for urban children under 5 (RR 2.1, 95% CI 1.0–4.2, P=0.04).
CONCLUSION Social marketing approaches to promoting insecticide-treated nets in Blantyre District may have produced measurable health benefits for children in those households in which residents bought and used the products. Market-based approaches may take years to achieve high levels of coverage and may exaggerate inequities between urban and rural populations.