Project

Community-based use and ownership of LLINs

Goal: Our overall goal is to determine multi-level social and environmental factors related to bednet ownership and use in two disparate transmission zones in western Kenya. We will translate this information into community-based interventions to improve bednet ownership and use of available bednets.

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Project log

Jenna Coalson
added 2 research items
Universal "coverage" with long-lasting insecticidal nets (LLINs) is recommended for malaria control in endemic areas, but ownership does not ensure usage. We evaluated relationships between household-level ownership and individual-level usage in western Kenya in 2015. Low-prevalence highland (> 1,500 m) and highly endemic lowland (< 1,200 m) sites were surveyed from July to August 2015. Household members reported long-lasting insecticidal net ownership, use, and barriers to use. Net ownership was categorized as sufficient (≤ 2 people/net), insufficient (> 2 people/net), or none. Each LLIN was assumed to provide access to two people. We surveyed 574 lowland and 643 highland households, with 1,677 and 2,742 members, respectively. More than 98% of lowland households owned LLIN(s); 72.1% owned a sufficient number. Only 37.5% of highland households had sufficient nets. More people used LLINs than were estimated to have access in the lowlands (94.2% versus 85.3%), but proportions were similar in the highlands (54.3% versus 53.3%). Insufficient ownership was most common for larger households in both areas and strongly predicted LLIN usage. In households with insufficient nets, men, school-age children (aged 5-15 years), and nonnuclear family members were less likely to use LLINs; only relationship to the head of the household significantly predicted use in households with sufficient nets. Long-lasting insecticidal nets were widespread in western Kenya in 2015, but insufficient household ownership remained common in the epidemic highlands and in large households. Access seemed to be the primary driver of individual use. To interrupt transmission, LLIN campaigns should improve distribution to large households and promote use among men, school-age children, and nonnuclear family members.
Background: Alternative long-lasting insecticidal net (LLIN) use for purposes other than sleeping protection from mosquitoes is widely debated as a limitation to successful malaria control efforts, yet rarely rigorously studied. Methods: A cross-sectional survey of 1217 households in an epidemic highland site and an endemic lowland site in western Kenya collected information on alternative use in three ways: direct observations, participant self-report, and participant reporting of community-level practices. LLIN misuse was defined as use of an intact net for alternative purposes and repurposing as alternatively using an old or damaged net. Associations between households with observed repurposed nets and universal access and household net use were examined. Results: Households describe repurposing nets when they are torn and/or old. Repurposed nets were observed in 8.1% (52/643) highlands households and 33.0% (184/574) lowlands households. Repurposed nets served as chicken coops (33% highlands, 20% lowlands), fences (37% highlands, 25% lowlands), tree covers (22% lowlands), curtains (3% highlands), covering bathrooms (1.5% highlands, 9% lowlands), and washing sponges (13% lowlands). No association was found between repurposing and universal access or household net use. Misuse was rare. Of 379 repurposed nets, 4 (1.06%) were in good condition with no holes. Of 1,758 active nets, 13 (0.74%) were misused. Conclusions: Alternative net use in this study involved repurposing rather than misuse. Repurposing was not detrimental to malaria prevention efforts in these communities. Standardized measurement of alternative net use should be used to better understand the practice and its potential impact on the success of malaria interventions.
Jenna Coalson
added a research item
Background: Insecticide-treated nets (ITNs) and long-lasting insecticidal nets (LLINs) are effective for malaria prevention and are designed to provide nearly 5 years of mosquito protection. However, many ITNs and LLINs become damaged and ineffective for mosquito bite prevention within 1 to 2 years in field conditions. Non-adherence to recommended bed net care and repair practices may partially explain this shortened net longevity. Methods: Using data from a cross-sectional study, a net care adherence score was developed and adherence to net care practices described from two regions of western Kenya. Relationships between attitudes and environmental factors that influence net longevity were measured with adherence to bed net care practices. Results: While overall care practices are highly adherent particularly in the highlands, practices related to daily storage, washing frequency, and drying location need improvement in the lowlands. Seventy-seven percent of nets in the lowlands were washed < 3 months prior to the survey compared to 23% of nets in the highlands. More nets were dried in the sun in the lowlands (32% of nets) compared to the highlands (4% of nets). Different elements of care are influenced by various malaria attitudes and environmental factors, highlighting the complexity of factors associated with net care. For example, households that learned about net care from community events, that share a sleeping structure with animals, and that have nets used by adult males tend to adhere to washing frequency recommendations. Conclusions: In western Kenya, many nets are cared for in accordance to recommended practices, particularly in the highlands sites. In the lowlands, demonstrating methods at community events to tie nets up during the day coupled with messaging to emphasize infrequent washing and drying nets in the shade may be an appropriate intervention. As illustrated by differences between the highlands and lowlands sites in the present study, should interventions to improve adherence to bed net care practices be necessary, they should be context-specific.
Jenna Coalson
added a project goal
Our overall goal is to determine multi-level social and environmental factors related to bednet ownership and use in two disparate transmission zones in western Kenya. We will translate this information into community-based interventions to improve bednet ownership and use of available bednets.
 
Douglas L Taren
added 2 research items
Ninety-eight percent of medical schools report nutrition as a component of medical education. However, most schools do not have an identifiable nutrition curriculum. Medical schools that do include nutrition have not evaluated its effect on clinical skills. The objective was to determine the efficacy of an integrated undergraduate medical curriculum to increase the quantity of nutrition instruction and to advance nutrition clinical skills demonstrated by medical students. A quasiexperimental design was constructed to determine whether an integrated nutrition curriculum increased the performance on nutrition-oriented clinical examinations of medical school classes that received 1, 2, or 3 y of the curriculum. The evaluation of the curriculum focused on 3 areas: 1) hours of nutrition instruction, 2) the application of nutrition within a clinical setting, and 3) perceptions about the nutrition curriculum. The Objective Structured Clinical Examination (OSCE) nutrition score was compared between graduating classes by use of analysis of variance. Data from the American Association of Medical Colleges were analyzed to determine the change in the proportion of students who reported that the amount of time devoted to nutrition was adequate. The implementation of the integrated nutrition curriculum resulted in a doubling of the total hours of required instruction in the medical curriculum (35 compared with 75 h). The mean (+/-1 SEM) OSCE nutrition score significantly improved after the implementation of the curriculum (41.7 +/- 0.9% compared with 50.6 +/- 1.1%) and the percentage of students who reported that the amount of nutrition taught during medical school was inadequate decreased (68.4% compared with 11.5%). Medical students improved their clinical nutrition practice skills through participation in an integrated nutrition curriculum.
Integrative health care (IH) is an approach to health that utilizes biomedical and social determinants of health to promote health and prevent disease, focusing on primary, secondary, and tertiary prevention, and utilizing not only the clinician–patient relationship but also how the family and community contribute to health promotion and disease. IH is a nascent area of practice within public health training. However, many people with a graduate degree in public health have a clinical profession that contributes to integrative primary health. To support the development of a competency-based education for IH, the National Center for Integrative Primary Healthcare convened an interprofessional leadership team to develop 10 “meta-competencies” in integrative primary health care. Following the development of the meta-competencies, individual members of the leadership team worked with colleagues within their profession to develop subcompetencies for specific professions for each meta-competency, including public health. The meta-competencies and public health subcompetencies were used to develop an online 33-hour introductory IH course: “Foundations in Integrative Health.” The public health subcompetencies were used to guide the development of a case study for a 6-hour unit, “Interprofessional Practice in Community Settings and Systems at Large,” on how to conduct and utilize a community health assessment that focused on health equity issues related to diabetes, which can also be taken as a stand-alone course.
Kacey C Ernst
added 2 research items
Anthropometric measurements, including height and length, are routinely needed for health research worldwide. Measurement boards are the current gold standard for obtaining the height and length of children. In community-based research, however, the size and weight of the measurement boards make them difficult and cumbersome to carry in the field. In addition, children and infants may express an unwillingness to be placed onto the measurement board. Electronic measuring tools commonly used in industry and contracting work are precise and portable. This study piloted a protocol to use an adapted laser measurement tool, the anthropometric measurement assist (AMA), to obtain height and recumbent length in children in Western Kenya. Intra- and inter-observer variability were determined and compared with measurement board measurements. Results of this initial pilot indicated that the AMA may be a viable alternative to measurement boards. The AMA can measure height/length accurately and reliably, is portable and is equivalent in price to measuring boards, making it a viable option for fieldwork in low-resourced countries.
Recent campaigns to increase the percent-age of households owning a bed net have been very successful yet there remains a subset of the population who do not sleep under bed nets. We used data from the 2008 Kenya Demographic and Health Survey (KDHS) to compare children under the age of five years of age who slept under any bed net to children sleeping without a bed net who resided in households with: i) no bed net; ii) all bed nets used (intra-household access); and iii) at least one unused bed net. Ownership, intra-house-hold access, and non-use of available bed nets were all associated with the child's age and the mother's relationship to the head of the house-hold. Intra-household access was strongly associated with provincial residence, where the child was born and frequency of reading newspapers. Furthermore, disuse of available nets for children was associated with marital status, bed net use of the head of the house-hold, and residing in rural communities at higher elevations. Improving bed net/long-last-ing insecticide treated nets (LLIN) use in Kenya requires a multi-faceted approach that addresses the complexity of the behavioral, social and economic drivers of non-use.
Kacey C Ernst
added a research item
Background Despite progress made in the last decades, malaria persists as a pressing health issue in sub-Saharan Africa. Pregnant women are particularly vulnerable to infection and serious health outcomes for themselves and their unborn child. Risk can be mitigated through appropriate use of control measures such as insecticide-treated bed nets. Although social networks can influence uptake of preventive strategies, the role of social influence on bed net ownership has not been explored. During an evaluation of a bed net distribution programme, the influence of non-health care advisors on ownership and use of bed nets by pregnant women in Kumasi, Ghana was examined. Methods Data were collected through in-person interviews with 300 pregnant women seeking antenatal care in an urban hospital in Kumasi, Ghana. Participants were asked about their bed net ownership, bed net use, and information about three personal contacts that they go to for pregnancy advice. Information about these advisors was combined into an influence score. Logistic regression models were used to determine the association between the score and bed net ownership. Those who owned a bed net were further assessed to determine if interpersonal influence was associated with self-reported sleeping under the bed net the previous night. Results Of the 294 women in the analysis, 229 (78%) reported owning bed nets. Of these bed net owners, 139 (61%) reported using a bed net the previous night. A dose response relationship was observed between the interpersonal influence score and bed net ownership and use. Compared to the lowest influence score, those with the highest influence score (>1 SD above the mean) were marginally more likely to own a bed net [OR = 2.37, 95% CI (0.87, 6.39)] and much more likely to use their bed net [5.38, 95% CI (1.89, 15.25)] after adjusting for other factors. Conclusions Interpersonal influence appears to have modest impact on ownership and use of bed nets by pregnant women in an urban area of Ghana. Further investigations would need to be conducted to determine if the relationship is causal or if individuals who associate are simply more likely to have similar practices. Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1660-4) contains supplementary material, which is available to authorized users.