From Distribution to Utilization: Identifying Implementation Gaps and Strategic Entry Points for Long-Lasting Insecticidal Net (LLIN) Programmes in a Conflict-Affected County of South Sudan

Background: Despite large-scale distribution of Long-Lasting Insecticidal Nets (LLINs) in South Sudan, utilization rates remain critically below the WHO 80% threshold. Fashoda County, Upper Nile State, presents a representative case of the wider implementation gap between net distribution and consistent household use in conflict-affected, resource-constrained settings. Methods: A cross-sectional analytical study was conducted among 334 households using probability-proportional-to-size (PPS) cluster sampling across four settlement types: IDP camps, returnee settlements, rural areas, and cattle camps. A programmatic cascade analysis and Health Belief Model (HBM) mapping were applied alongside Spearman rank correlation and ordinal logistic regression to identify implementation failure points and priority intervention entry points. Results: A programmatic coverage cascade revealed successive losses from distribution (89%) through ownership, hanging, and previous-night use to consistent utilization (50.3%) and whole-household coverage (44.3%)—well below the WHO 80% target. Regression analysis identified preference for government-supplied free nets (β = +45.10, p < 0.001), household economic ambiguity (β = −62.00, p < 0.001), and easy physical access (β = +6.19, p < 0.001) as the dominant implementation levers. Cultural discouragement independently suppressed utilization (β = −1.21, p = 0.027). A policy priority matrix identified Behaviour Change Communication and ANC-integrated continuous distribution as the highest-impact, most-feasible interventions. Conclusions: The distribution-to-utilization gap in Fashoda County reflects a systemic implementation failure across knowledge, economic, cultural, and logistical domains. Addressing this gap requires a paradigm shift from cam