Determinants of bed net policy implementation: A case study of Southern Benin.

BACKGROUND: Malaria is a major global health challenge. This study aims to clarify the manner in which contextual factors determine the use and maintenance of bed nets and the extent to which malaria prevention policy is responsive to them in Southern Benin.

METHODS: Semi-structured interviews and direct observations were undertaken with 30 pregnant women in the municipality of So-Ava from June to August 2015. Key informants in the Ministry of Health and local community health workers were also interviewed regarding malaria prevention policy formation, and the monitoring and evaluation of bed net interventions, respectively. Data were analyzed through categorical content analysis and grouped into themes.

RESULTS: The majority of pregnant women participants (80%) declared non-adherence to instructions for hanging and maintaining insecticide-treated nets (ITNs). The distributed bed nets were washed like clothes, which affected their bio-efficacy, and were in poor condition (ie, torn or had holes). Multiple factors contributed to the poor condition of ITNs: Pregnant women's limited understanding of risk including their inability to connect the key environmental factors to personal risk, gendered responsibility for installing bed nets, and lack of public measures that would enable women to re-treat or access new bed nets as needed. Poverty that determined structural aspects of housing such as the size and quality of homes and access to bed nets exacerbated the challenges.

CONCLUSION: Institutionalizing an iterative process of monitoring, review, and responsive adaptation throughout the entire policymaking cycle would better support malaria preventive policy implementation in Benin.