While ITN household possession and use among children has increased dramatically since 2005 as a result of intensive investments across Africa 
, a number of cross-sectional studies prior to 2005 showed ITN use to be quite low 
. Such studies likely contributed to the first misconception that many people given ITNs refuse to use them, especially when given out for free. However, much of the low use among children prior to 2005 was a result of households not having access to ITNs; if you do not have one, you cannot use one. A study of 15 nationally representative surveys between 2003 and 2006 showed that the biggest determinant of ITN use was intra-household access to them; the more nets a household has, the more likely a child in the house will use one 
. This same study also showed that a third of the countries analyzed had more than 60% ITN usage among children in households possessing them; importantly, many (range 18%–70%) of the nets unused by children were being used by adults in the households. Additionally, there are cross-sectional data from Niger and Kenya that show nearly all (≥95%) ITNs received from mass free distribution are retained by the households, countering the argument that many nets distributed for free are sold or traded 
. Finally, it is important to note that in areas with high household coverage, ITNs confer protection to individuals not using them through community-level protection from reduced vector densities 
We identified only one peer-reviewed study that reported misuse of ITNs 
. This study was a non-probability survey of seven beaches on Lake Victoria in western Kenya, making the conclusions non-generalizable. However, data from a 2008 cross-sectional study in the Luangwa District in Zambia, a district bordered by the Luangwa and Zambezi rivers with a population heavily reliant on fishing 
, and where ITN household possession is greater than 80%, show that only 3% of households reported using their ITNs for purposes other than protection against mosquitoes (K. Macintyre, M. Littrell, J. Keating, J. Miller, T. P. Eisele, unpublished data). This is supported by findings from a qualitative study in Ethiopia that also found misuse of nets to be an uncommon problem 
We should remember that long-lasting insecticide-treated nets typically wear out after 2–3 years 
. Therefore, we hypothesize that at least some of the anecdotal reports of nets being used for such things as fishing and weddings may actually be worn-out nets no longer in use for protection against mosquitoes, and thus their use for such purposes would not really constitute misuse of an effective ITN. It is critical that strategies are developed within countries to replace such worn-out nets with new, effective ITNs through keep-up campaigns 
. It is also important to note that appropriate use of an ITN happens at night in the home and is therefore not visible in the same way that misuse of a net is for such things as fishing and weddings.
While mosquito nets impregnated with insecticides are a relatively new Western technology (circa the 1940s), many African communities have long used mosquito nets as protection against nuisance biting insects 
. However, access to mosquito nets, especially ITNs, remained appallingly low across most of Africa prior to the scale-up that began around 2005. In an attempt to rapidly achieve high coverage among vulnerable populations, the malaria control community has increasingly relied on mass distribution of free ITNs through campaigns. While it is true that mass distribution campaigns have largely been implemented in a top-down fashion, they have been shown to be more effective at rapidly achieving high and equitable coverage compared to social marketing of ITNs through the private sector 
. It is also widely recognized that social marketing of ITNs for sale at subsidized prices through the public and private sector will be needed to sustain the coverage achieved through mass free campaigns 
. As such, there has been a concerted effort by researchers to gather data on community preferences of ITN shapes, colors, and sizes to ensure they meet community preferences and maximize acceptability 
. While more should be done to empower local communities to better implement malaria control interventions, the argument that ITN promotion fails to consider local cultural preferences is inaccurate.