Article

Insecticide-treated net ownership and use in Niger after a nationwide integrated campaign

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

In December 2005 and March 2006, Niger conducted nationwide integrated campaigns to distribute polio vaccine and long lasting insecticide-treated nets (LLINs) to children <5 years of age. We evaluated the campaign effectiveness, net retention, insecticide-treated net (ITN) ownership, and usage. Two nationwide cross-sectional surveys in January 2006 (dry season) and September 2006 (rainy season), using a stratified two-stage cluster sampling design. We mapped selected communities, selected households by simple random sampling, and administered questionnaires by interviewers using personal digital assistants. The first survey showed that ITN ownership in all households was 6.3% prior to the campaign, increasing to 65.1% after the campaign in the second survey. The second survey also showed that 73.4% of households with children <5 received an LLIN and that 97.7% of households that received > or = one LLIN retained it. The wealth equity ratio for ITN ownership in households with children <5 increased from 0.17 prior to the campaign to 0.79 afterward. During the dry season, 15.4% of all children <5 and 11.3% of pregnant women slept under an ITN, while during rainy season, 55.5% of children <5 and 48.2% of pregnant women slept under an ITN. Free distribution during the integrated campaign rapidly increased ITN ownership and decreased inequities between those in the highest and lowest wealth quintiles. Retention of ITNs was very high, and usage was high during malaria transmission season. However, ITN ownership and usage by vulnerable groups continues to fall short of RBM targets, and additional strategies are needed to increase ownership and usage.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... 2,16,17 With the launch of the initiative, the distribution of ITNs shifted from targeted distribution to mass distribution campaigns. This shift gave malaria control programmes the opportunity to reduce disparities among subgroups by increasing ITN ownership [18][19][20][21][22][23][24] to reduce the malaria burden. 25 The mass distribution campaigns aim to provide one ITN for every two household members. ...
... This finding could be due to early implementation of focused nationwide campaigns where ITN distributions were integrated with child health campaigns. 19,[40][41][42] In Mali and Mozambique, ITN ownership remained equitably distributed in endpoint surveys, possibly due to the rollout of net-distribution campaigns to achieve universal coverage in 2008 and 2011. 43,44 However, Angola and Niger experienced a decrease in equity in their endpoint surveys despite low inequity at baseline. ...
... 45 Reasons for the worsened equity in Niger is less clear, but possible explanations could include the lack of implementation of free ITN distribution campaigns between baseline and endpoint surveys. 19,25 Madagascar and Senegal were the only countries that maintained levels of inequity from base-line to endpoint in favour of households from the lowest wealth quintiles. The trend seen in Congo, Guinea, Nigeria, Sierra Leone and Zimbabwei.e. ...
Article
Full-text available
Objective To examine the change in equity of insecticide-treated net (ITN) ownership among 19 malaria-endemic countries in sub-Saharan Africa before and after the launch of the Cover The Bed Net Gap initiative. Methods To assess change in equity in ownership of at least one ITN by households from different wealth quintiles, we used data from Demographic and Health Surveys and Malaria Indicator Surveys. We assigned surveys conducted before the launch (2003–2008) as baseline surveys and surveys conducted between 2009–2014 as endpoint surveys. We did country-level and pooled multicountry analyses. Pooled analyses based on malaria transmission risk, were done by dividing geographical zones into either low- and intermediate-risk or high-risk. To assess changes in equity, we calculated the Lorenz concentration curve and concentration index (C-index). Findings Out of the 19 countries we assessed, 13 countries showed improved equity between baseline and endpoint surveys and two countries showed no changes. Four countries displayed worsened equity, two favouring the poorer households and two favouring the richer. The multicountry pooled analysis showed an improvement in equity (baseline survey C-index: 0.11; 95% confidence interval, CI: 0.10 to 0.11; and endpoint survey C-index: 0.00; 95% CI: −0.01 to 0.00). Similar trends were seen in both low- and intermediate-risk and high-risk zones. Conclusion The mass ITN distribution campaigns to increase coverage, linked to the launch of the Cover The Bed Net Gap initiative, have led to improvement in coverage of ITN ownership across sub-Saharan Africa with significant reduction in inequity among wealth quintiles.
... Across Africa, different distribution strategies such as fixed or door-to-door delivery have been used with varying effects on LLIN coverage and use. Furthermore, despite overall LLIN scale-up, several other factors still influence LLIN use including demographic characteristics; individual's knowledge and beliefs related to malaria and LLIN; dwelling construction, family size, sleeping arrangements; LLIN characteristics; environmental factors; community and cultural characteristics; distribution strategy and household net density [5,6,[8][9][10][11]. ...
... Full details are described by Kilian et al. [21]); (4) proportion of population that slept under a LLIN the previous night; (5) proportion of children under 5 years old who slept under a LLIN the previous night; (6) proportion of pregnant women who slept under a LLIN the previous night; (7) proportion of existing LLINs used the previous night. Case management indicators: (8) proportion of children less than 5 years old with fever in the last 2 weeks who had a finger or heel stick; (9) proportion of children less than 5 years old with fever in the last 2 weeks for whom advice or treatment was sought; (10) proportion receiving an ACT (or other appropriate treatment), among children less than 5 years old with fever in the last 2 weeks who received any anti-malarial drugs. Morbidity indicators: (11) malaria prevalence, defined as the proportion of children aged 6-59 months with a positive RDT; (12) anaemia prevalence, defined as the proportion of children aged 6-59 months with haemoglobin rate <8 g/dl. ...
... As could be expected after a free LLIN mass distribution campaign that targeted the entire population at risk for malaria, equity in household LLIN coverage and individual use of LLIN has been improved as demonstrated by the Lorenz curve meeting the equity line as well as the concentration index shifting from positive to close to zero values. These findings corroborate results from other mass distribution campaigns showing equitable LLIN ownership and use [8,22,30,31]. ...
Article
Full-text available
Background Long-lasting insecticidal nets (LLIN) are a highly effective means for preventing malaria infection and reducing associated morbidity and mortality. Mass free distribution campaigns have been shown to rapidly increase LLIN ownership and use. Around 3.5 million LLINs were distributed free of charge in the Kasaï Occidental Province in the Democratic Republic of Congo (DRC) in September–October 2014, using two different approaches, a fixed delivery strategy and a door-to-door strategy including hang-up activities. Methods Repeated community-based cross-sectional surveys were conducted 2 months before and six months after the mass distribution. Descriptive statistics were used to measure changes in key malaria household indicators. LLIN ownership and use were compared between delivery strategies. Univariate and multivariate logistic regression analyses were used to identify factors associated with LLIN use before and after the mass distribution. A comparative financial cost analysis between the fixed delivery and door-to-door distribution strategies was carried out from the provider’s perspective. Results Household ownership of at least one LLIN increased from 39.4% pre-campaign to 91.4% post-campaign and LLIN universal coverage, measured as the proportion of households with at least one LLIN for every two people increased from 4.1 to 41.1%. Population access to LLIN within the household increased from 22.2 to 80.7%, while overall LLIN use increased from 18.0 to 68.3%. Higher LLIN ownership was achieved with the fixed delivery strategy compared with the door-to-door (92.5% [95% CI 90.2–94.4%] versus 85.2% [95% CI 78.5–90.0%]), while distribution strategy did not have a significant impact on LLIN use (69.6% [95% CI 63.1–75.5%] versus 65.7% [95% CI 52.7–76.7%]). Malaria prevalence among children aged 6–59 months was 44.8% post-campaign. Living in a household with sufficient numbers of LLIN to cover all members was the strongest determinant of LLIN use. The total financial cost per LLIN distributed was 6.58 USD for the fixed distribution strategy and 6.61 USD for the door-to-door strategy. Conclusions The mass distribution campaign was effective for rapidly increasing LLIN ownership and use. These gains need to be sustained for long-term reduction in malaria burden. The fixed delivery strategy achieved a higher LLIN coverage at lower delivery cost compared with the door-to-door strategy and seems to be a better distribution strategy in the context of the present study setting.
... A core focus of free mosquito net distribution campaigns has been equitable coveragewithin and between populations-with the goal of reducing disparities in access to preventive measures for economically or socially marginalized sub-populations. Previous studies show that large-scale, free net distribution campaigns can reduce inequities in household net ownership across socio-economic gradients, relative to other forms of distribution [5][6][7][8][9][10]. Inequities in ownership and use may still persist, however, preventing those among the lowest socioeconomic strata from accessing and retaining malaria preventative measures [10,11]. ...
... In our study, a year and a half after the LLIN distribution only 32% of households that initially received nets reported owning at least one LLIN. The observed rate of LLIN attrition for Batwa households six months after distribution, a year after distribution, and a year and a half after distribution, was among the highest found in comparable studies done in sub-Saharan Africa [5,6,8,9,11,13,14,16,[41][42][43]. This highlights the need for better estimates of malaria intervention coverage for highly marginalized sub-populations in these regions. ...
... Furthermore, the equity ratios of household LLIN ownership tended towards increasing inequity (ratio's decreased) over the course of the study period, reflecting a widening of the gap in LLIN retention between the least poor and the poorest Batwa households. However, our findings are inconsistent with those of Larson et al (2014) that found, after a targeted LLIN distribution, social factors (i.e., maternal education and household wealth) no longer predicted the use of nets [8] and that inequities between social groups in net ownership and use were reduced [5][6][7]9]. The scale at which our study was conducted only allowed us to make statistical inferences about the impact of socioeconomic factors on retention of LLINs between Batwa households. ...
Article
Full-text available
Major efforts for malaria prevention programs have gone into scaling up ownership and use of insecticidal mosquito nets, particularly in sub-Saharan Africa where the malaria burden is high. Socioeconomic inequities in access to long lasting insecticidal nets (LLINs) are reduced with free distributions of nets. However, the relationship between social factors and retention of nets after a free distribution has been less studied, particularly using a longitudinal approach. Our research aimed to estimate the ownership and use of LLINs, and examine the determinants of LLIN retention, within an Indigenous Batwa population after a free LLIN distribution. Two LLINs were given free of charge to each Batwa household in Kanungu District, Uganda in November 2012. Surveyors collected data on LLIN ownership and use through six cross-sectional surveys pre- and post-distribution. Household retention, within household access, and individual use of LLINs were assessed over an 18-month period. Socioeconomic determinants of household retention of LLINs post-distribution were modelled longitudinally using logistic regression with random effects. Direct house-to-house distribution of free LLINs did not result in sustainable increases in the ownership and use of LLINs. Three months post-distribution, only 73% of households owned at least one LLIN and this period also saw the greatest reduction in ownership compared to other study periods. Eighteen-months post distribution, only a third of households still owned a LLIN. Self-reported age-specific use of LLINs was generally higher for children under five, declined for children aged 6–12, and was highest for older adults aged over 35. In the model, household wealth was a significant predictor of LLIN retention, controlling for time and other variables. This research highlights on-going socioeconomic inequities in access to malaria prevention measures among the Batwa in southwestern Uganda, even after free distribution of LLINs, and provides critical information to inform local malaria programs on possible intervention entry-points to increase access and use among this marginalized population.
... Free mass distributions have been identified as the best means to reduce disparities in LLIN ownership, and subsequent campaigns have had a great impact on equalizing ownership across wealth classes [5][6][7][8]. However, in some regions, these disparities still remain [6,9]. ...
... Evidence is building about what happens to LLINs following mass distribution campaigns, however, there are mixed results from different studies. Some previous studies have indicated that use of distributed LLINs is low [5,11,15,16] while others indicate that most LLINs that are distributed are used for their intended purpose [17][18][19]. Some evidence suggests that while there are many reported challenges in using LLINs, including shape, inconvenience, heat, and discomfort, most individuals report using their LLIN the night prior to the interview [17]. ...
... In addition multivariable models of ownership of bed nets in the highlands revealed a moderate association with wealth that was not identified in the lowland community. Other studies have demonstrated that with greater access there is a shift in factors associated with bed net ownership but have primarily focused on shifts in the wealth gap and less on associations with perceptions and attitudes about malaria [5,8]. Further, this difference in risk factors associated with ownership does not appear to be driven by site-level differences in perceptions and attitudes towards malaria as these differences were minimal and there were no associations between these factors and ownership of bed nets ( Table 2). ...
Article
Full-text available
Background Challenges persist in ensuring access to and optimal use of long-lasting, insecticidal bed nets (LLINs). Factors associated with ownership and use may differ depending on the history of malaria and prevention control efforts in a specific region. Understanding how the cultural and social-environmental context of bed net use may differ between high- and low-risk regions is important when identifying solutions to improve uptake and appropriate use. Methods Community forums and a household, cross-sectional survey were used to collect information on factors related to bed net ownership and use in western Kenya. Sites with disparate levels of transmission were selected, including an endemic lowland area, Miwani, and a highland epidemic-prone area, Kapkangani. Analysis of ownership was stratified by site. A combined site analysis was conducted to examine factors associated with use of all available bed nets. Logistic regression modelling was used to determine factors associated with ownership and use of owned bed nets. Results Access to bed nets as the leading barrier to their use was identified in community forums and cross-sectional surveys. While disuse of available bed nets was discussed in the forums, it was a relatively rare occurrence in both sites. Factors associated with ownership varied by site. Education, perceived risk of malaria and knowledge of individuals who had died of malaria were associated with higher bed net ownership in the highlands, while in the lowlands individuals reporting it was easy to get a bed net were more likely to own one. A combined site analysis indicated that not using an available bed net was associated with the attitudes that taking malaria drugs is easier than using a bed net and that use of a bed net will not prevent malaria. In addition, individuals with an unused bed net in the household were more likely to indicate that bed nets are difficult to use, that purchased bed nets are better than freely distributed ones, and that bed nets should only be used during the rainy season. Conclusion Variations in factors associated with ownership should be acknowledged when constructing messaging and distribution campaigns. Despite reports of bed nets being used for other purposes, those in the home were rarely unused in these communities. Disuse seemed to be related to beliefs that can be addressed through education programmes. As mass distributions continue to take place, additional research is needed to determine if factors associated with LLIN ownership and use change with increasing availability of LLIN.
... In addition, the malaria parasite stays and replicates in the placenta, which makes pregnant women three times more likely to suffer from malaria than those of non-pregnant. It is also noticeable that malaria in pregnancy period can lead to miscarriage, low birth weight baby, premature delivery, congenital However, high level of coverage always depends on mass distribution of LLINs (Teklehaimanot, Sachs, & Curtis, 2007), including free distribution for equitable coverage (Thwing et al., 2008). ...
... However, ownership of only one LLIN is not sufficiently enough to eliminate malaria completely from the country and achieve the sustainable development goal of establishing a malaria free world (Norheim et al., 2015;UN, 2018). Rather, it requires the distribution of one LLIN for every two people and three LLINs for a family size of five people (Thwing et al., 2008). identified that migration and exclusion of bachelor/single people from the distribution were two major reasons for not achieving the universal LLIN coverage . ...
... LLIN mass distribution campaigns and supplementary distribution through antenatal clinics and immunization services have largely been successful in achieving increased LLIN ownership and universal LLIN coverage in the population [8][9][10][11][12][13]. Several African studies have shown an apparent difference in adequate LLIN possession (one LLIN per two person) and LLIN use by the community [14][15][16][17][18]. Therefore, routine monitoring for LLIN use and regular community-tailored education and awareness campaigns may be vital to sustain the utilization and to optimize the protective effect of LLINs [12,19]. ...
... Similar findings were reported by Ntuku et al. [13]. Likewise, larger households found to have lower net use was also reported in African studies [14][15][16][17]. ...
Article
Full-text available
Background Despite the known effectiveness of long-lasting insecticidal nets (LLINs) in providing protection against malaria, high level of ownership and use are very difficult to achieve and maintain. Nearly 40,000 LLINs were distributed in 2014 as an intervention tool against malaria transmission in 80 villages of Keshkal sub-district in Chhattisgarh, India. This study assessed LLIN coverage, access, utilization pattern, and key determinants for the net use 1 year after mass distribution. Methods In 2015, a cross-sectional household survey was carried out in 80 study clusters (whole village or part of village). From each cluster, 40 households were randomly selected and interviewed using a structured questionnaire adapted from the malaria indicator survey of Roll Back Malaria guidelines. Information on demographic characteristics, LLIN ownership, and its use on the night before the survey, and physical condition of LLINs were recorded. Results 2970 households were interviewed with a total of 15,003 individuals present in the households during the night before the survey. Nearly 98% of households had at least one LLIN and 59.4% of the surveyed population reportedly used an LLIN the previous night. LLIN use varied from 41 to 94% between the study clusters. Nearly 89% of the LLINs were found in good physical condition (without holes). However, proportion of household with at least one LLIN per two persons was only 39%. Conclusion Universal coverage of LLINs was inadequate in the study clusters making it difficult for all household members to use an LLIN. LLIN use varied between clusters and was highest in children under 5 years of age. Health education campaigns and creating awareness about the benefit of sleeping under the LLINs in providing protection against malaria is required not only to high risk groups of pregnant women and children below 5 years of age but all the members of the family to have an epidemiological impact of this intervention at the community level. Relatively high net use despite poor access to LLINs indicates an overall desire to use nets when they are available. The main barrier to increased use of nets is the low coverage at household level.
... In 2005 and 2009, Niger distributed free of charge more than six million long-lasting insecticidal nets (LLINs) to pregnant women and children below 5 years of age thanks to the support of its collaborators [2]. In 2014, distribution of more than three million LLINs to the whole population was carried out in two regions. ...
... LLIN usage was implemented in the seven sites, where the rate of LLIN ownership in households increased from 6.3% prior LLIN mass distribution in December 2005 to 61.1% in 2006 [2]. This high rate of LLIN usage in Niger may have triggered this resistance previously described in the country [4,22,23] and in Benin [6]. ...
Article
Introduction: We performed a transversal study to map resistance of malaria vectors (Anopheles mosquitoes) to insecticides in Niger within the frame of the National Malaria Control Program funded by the World Health Organization (WHO). Method: Larvae of Anopheles gambiae s.l were collected from November to December 2013 in seven locations selected on the basis of different patterns of use of insecticides and environment. WHO susceptibility test tubes were used on females Anopheles to detect resistance to insecticides. Eight insecticides were tested. Percentages of knockdown during exposure time to pyrethroids and DDT and mortality after 24hours of observation for all tested insecticides were calculated. PCR and biochemical tests were carried out to identify the species and mechanisms of resistance (Kdr allele frequencies and activity of detoxification enzymes). Results: In all sites, Anopheles gambiae s.l was susceptible to bendiocarb and malathion but resistant to the five pyrethroids and DDT (24-hour mortality rate was <90%). The Kdr mutation was present in the molecular form M of Anopheles gambiae with an average frequency of 58%. Biochemical tests showed the activity of various enzyme families (esterase, oxidase, and glutathione s-transferase). Conclusion: This study showed multiple resistance of Anopheles mosquitoes to insecticides in Niger. A rigorous management of this resistance is imperative to preserve the efficacy of pyrethroids as it is the only class of insecticides used for insecticide-treated nets.
... La CPS consiste à administrer de façon intermittente, les traitements complets par un médicament antipaludique (AQ+SP) aux enfants de 3 à 59 mois au cours de la saison de haute transmission du paludisme pour éviter la maladie et ceci, en maintenant des concentrations thérapeutiques en médicament antipaludique dans le sang pendant toute cette période (OMS, 2015). Au Niger, 54,82% d'enfant et 48,21% des femmes enceintes ont dormi sous moustiquaire la nuit précédant une enquête (Thwing et al., 2008). Au Sénégal, environ trois enfants sur dix dorment sous MILDA (Ndiaye et al., 2007). ...
... Cet auteur rapporte que 80,6% des Maliens possèdent des MILDA. Toutefois, les taux obtenus au Tchad et au Mali sont supérieurs à ceux rapportés par Faye (2008) (76,7%) et l'enquête CDC (65%) au Niger (Thwing et al., 2008). Il faut noter qu'au Tchad, la distribution des MILDA est fortement décentralisée et gratuite. ...
Article
L’utilisation des Moustiquaires Impregnees d’Insecticide a Longue Duree d’Action (MILDA) et la chimio - prevention du paludisme sont des strategies efficaces de lutte contre le paludisme. L’objectif de cette etude est d’evaluer le niveau de connaissance de la communaute sur le paludisme et l’utilisation des MILDA. Une etude descriptive a ete effectuee au Tchad, sur la base des questionnaires administres aux chefs de menages. Les donnees collectees ont ete saisies a l’aide du logiciel Acces 2007, nettoyees et validees au cours d’un atelier a N’Djamena. Des 2000 personnes enquetes, 1388 (69,4%) reponses ont ete satisfaisantes selon les criteres utilises. Un taux de 80,6% des enquetes declarent disposer des MILDA, et 37,6% de ce taux affirment les avoir utilisees la nuit precedant l'enquete. Cependant, 68,2% des repondants percoivent que le paludisme est dangereux pour le foetus et les femmes enceintes. Aussi, 50.4% d’individus affirment dormir sous la MILDA a partir de 20 heures. Cette etude a montre que malgre que le paludisme soit la premiere cause de consultations medicales au Tchad, certaines personnes ne percoivent pas les risques de cette maladie. Plus de la moitie des personnes disposant des MILDA ne les ont pas utilises a la veille de l’enquete. © 2016 International Formulae Group. All rights reserved. Mots cles: Paludisme, connaissance, moustiquaire, utilisation, Tchad English Title: Perception of malaria risk and use of bed nets in Chad English Abstract The use of Long Lasting Insecticidal-treated Nets (LLINs) and the seasonal malaria chemoprevention are efficient strategies in the fight against malaria. The objective of this survey is to assess the community knowledge about malaria and LLIN use. A descriptive households’ survey has been conducted in Chad using questionnaires targeting the head of households. Data collected were entered in Access 2007, cleaned and validated during a workshop held in N’Djamena. Of the 2,000 people targeted, 1,388 (69.4%) responses satisfied all the criteria. 80.6% of the respondents declared owning a LLIN but only 37.6% of those state having used it the night prior to the interview. 68.2% of the respondents perceive malaria as dangerous for the fetus and the pregnant women. 50.4% of the respondents state sleeping under the LLIN starting at 8 pm. This survey shows that despite being the first cause of out-patient visits in Chad, risks related to malaria are not fully perceived by the population. More than half of the respondents owning a LLIN did not sleep under it the night prior to the survey. © 2016 International Formulae Group. All rights reserved. Keywords: malaria, knowledge, mosquito net use, Chad
... Other authors [40] described the process indicators, results and impact of malaria control which were useful for the implementation of the monitoring and assessment system of ''Roll Back Malaria'' in Benin. The large scale and selective distribution of LLINs in Africa in the last decade were also the subject of several studies which concerned mainly the acceptability and/or the population perception without investigating their parasitological and clinical effects [41][42][43][44][45][46][47]. Pyrethroid resistance in malaria vectors has been observed in many African countries [7]. ...
... Throughout the 12 months of the study, two children out of three were found sleeping under LLINs during unannounced and nocturnal inspections. Some studies have already concluded that free distribution of nets via a national campaign is effective in rapidly increasing their possession and use [42,57,58]. This high percentage of use may have been the result of adapted sensitization to the beliefs and behaviours of the communities and to the presence of medical staff assisted by a local village helper. ...
... Other authors [40] described the process indicators, results and impact of malaria control which were useful for the implementation of the monitoring and assessment system of ''Roll Back Malaria'' in Benin. The large scale and selective distribution of LLINs in Africa in the last decade were also the subject of several studies which concerned mainly the acceptability and/or the population perception without investigating their parasitological and clinical effects [41][42][43][44][45][46][47]. Pyrethroid resistance in malaria vectors has been observed in many African countries [7]. ...
... Throughout the 12 months of the study, two children out of three were found sleeping under LLINs during unannounced and nocturnal inspections. Some studies have already concluded that free distribution of nets via a national campaign is effective in rapidly increasing their possession and use [42,57,58]. This high percentage of use may have been the result of adapted sensitization to the beliefs and behaviours of the communities and to the presence of medical staff assisted by a local village helper. ...
Thesis
Full-text available
Combination of unrelated insecticides in the same dwelling is a possible strategy for insecticide resistance management in malaria vectors. These combinations aim to interrupt the transmission and to manage the insecticides resistance in vectors. Here, we investigated the combined efficacy of a Long Lasting Insecticidal Nets (LLIN) plus a Carbamate Treated Plastic Sheeting (CTPS) or an IRS using bendiocarb. Under laboratory conditions, we tested the wash resistance of four different subtracts. Then, the combined efficacy of a LLIN (PermaNet 2.0) plus a CTPS or an IRS using bendiocarb against resistant malaria vectors was investigated in experimental huts. Finally, through a randomized controlled trial in Ouidah-Kpomasse-Tori health district in south Benin, the impact of the use of LLIN alone and in combination with CTPS or IRS on malaria incidence and transmission as well as on the management of insecticide resistance in malaria vectors was assessed. Variation at 11 microsatellite loci was also investigated to assess the impact of intervention on the genetic structure of Anopheles funestus. Four malaria vector control strategies were evaluated: i) Long-Lasting Insecticidal Nets (LLNs) targeted coverage of children under 5 years old like the National Malaria Control Programme (control); ii) LLNs universal coverage of sleeping units (LLIN); iii) LLINs universal coverage + CTPS at the dose 200 mg/m², re-impregnated every four months; recommended doses of bendiocarb for residual application are 100-400 mg/m² (LLIN + CTPS); iv) LLINs targeted coverage plus annual bendiocarb IRS (IRS). Under laboratory, material made of polypropylene mesh provided the best wash resistance (up to 10 washes). In experimental huts, results showed a clear benefit for combining the two interventions in terms of blood feeding inhibition and mortality, notably in area where vectors are resistant to pyrethroids, carbamates (and organophosphorus). In contrast, randomized controlled trial did not show the benefit in terms of malaria transmission reduction, and malaria infection and disease reduction in children under 5 years old, when unrelated insecticides were combined in the same dwelling. Concerning resistance management in malaria vectors, the allelic frequency of kdr mutation increased during the 18 months of survey (from 29% to 84% on average). The genetic diversity of An. funestus population was not significantly affected since different genetic parameters (allele number, observed and expected heterozygosities) remained stable. The coverage rate of LLIN was satisfactory (75%), but the use rate (46%) was lower than the threshold fixed in the study (70%). Results of the randomized controlled trial can be explained by several factors as anthropological and sociological factors (perception and use of the treatments), operational factors (residual life of the bendiocarb, wall coverage with CTPS), biological factors (vectors behavior) and epidemiological factors (low level of transmission in the study area). It would be now useful to confirm or to invalidate these results in another entomological (transmission and resistance of vectors) and epidemiological facies in order to demonstrate the interest of these combinations at an operational scale.
... In Nigeria, this model led to increased awareness on other vaccine preventable diseases (such as measles, cerebrospinal meningitis, yellow fever, pertussis) and increased access to health services at the nearest health facility [18]. Similarly, following an integrated campaign for insecticide treated nets (ITN) and polio vaccination in Niger, there was substantial increase in ITN ownership with accompanied decrease in inequities between highest and lowest wealth quintiles [45]. ...
Article
Full-text available
Background Improving service delivery is a key strategy for achieving service coverage, one of the two components of universal health coverage (UHC). As one of the largest global public health initiatives, individuals involved with the Global Polio Eradication Initiative (GPEI) have learned many important lessons about service delivery. We identified contributors and challenges to delivering health services at national and subnational levels using experiences from the GPEI. We described strategies used to strengthen service delivery and draw lessons that could be applicable to achieving UHC. Methods Online cross-sectional surveys based on the Consolidated Framework for Implementation Research (CFIR) domains and socioecological model were conducted from 2018–2019. Data were analyzed using an embedded mixed methods approach. Frequencies of the contributors and challenges to service delivery by levels of involvement were estimated. Chi-square tests of independence were used to assess unadjusted associations among categorical outcome variables. Logistic regressions were used to examine the association between respondent characteristics and contributors to successful implementation or implementation challenges. Horizontal analysis of free text responses by CFIR domain was done to contextualize the quantitative results. Results Three thousand nine hundred fifty-five people responded to the online survey which generated 3,659 valid responses. Among these, 887 (24.2%) reported involvement in service delivery at the global, national, or subnational level with more than 90% involved at subnational levels. The main internal contributor of strengthened service delivery was the process of conducting activities (48%); working in frontline role had higher odds of identifying the process of conducting activities as the main internal contributor (AOR: 1.22, p = 0.687). The main external contributor was the social environment (42.5%); having 10–14 years of polio program implementation was significantly associated with identifying the social environment as the main external contributor to strengthened service delivery (AOR: 1.61, p = 0.038). The most frequent implementation challenge was the external environment (56%); working in Eastern Mediterranean region was almost 4 times more likely to identify the external environment as the major challenge in service delivery strengthening (AOR:3.59, p < 0.001). Conclusion Priority actions to improve service delivery include: adopt strategies to systematically reach hard-to-reach populations, expand disease-focused programs to support broader primary healthcare priorities, maximize community outreach strategies to reach broader age groups, build community trust in health workers and develop multisectoral leadership for collaboration. Achieving UHC is contingent on strengthened subnational service delivery.
... following an integrated campaign for insecticide treated nets (ITN) and polio vaccination in Niger, there was substantial increase in ITN ownership with accompanied decrease in inequities between highest and lowest wealth quintiles. (45) Currently, there is a focus on integration of implementation of PEI and RI as evidenced by the recent strategic plans of Gavi Phase V (2021-2025),(46) the upcoming Polio Eradication Strategy (2022-2026), (47) and the launch of the interim Program of Work for Integrated Actions that synergizes GPEI and the Essential Programme on Immunization (EPI) in the context of COVID-19. ...
Preprint
Full-text available
Background Improving service delivery is a key strategy for achieving service coverage, one of the two components of universal health coverage (UHC). As one of the largest global public health initiatives, individuals involved with the Global Polio Eradication Initiative (GPEI) have learned many important lessons about service delivery. We identified contributors and challenges to delivering health services at national and subnational levels using experiences from the GPEI. We described strategies used to strengthen service delivery and draw lessons that could be applicable to achieving UHC. Methods Online cross-sectional surveys based on the Consolidated Framework for Implementation Research (CFIR) domains were conducted from 2018-2019. Data were analyzed using an embedded mixed methods approach. Frequencies of the contributors and challenges to service delivery by levels of involvement were estimated. Chi-square tests of independence were used to assess unadjusted associations among categorical outcome variables. Logistic regressions were used to examine the association between respondent characteristics and contributors to successful implementation or implementation challenges. Horizontal analysis of free text responses by CFIR domain was done to contextualize the quantitative results. Results Among the 3,659 survey respondents, 887 (24.2%) reported involvement in strengthening service delivery at the global, national, or subnational level with more than 90% involved at subnational levels. The most important internal contributor to strengthening service delivery was the process of conducting activities (48%), e.g., microplanning, and strategies to reach high-conflict or remote populations. The highest external contributor was the social environment (42.5%), e.g., community awareness and trust in health workers. Respondents working at national and subnational levels had four times significantly higher odds (adjusted odds ratio = 4.26, p=0.007) of identifying the external environment e.g., insecurity and community resistance, as the biggest challenge to service delivery, compared to those in advisory roles. Strategies for mitigating community resistance included use of indigenous community volunteers, social mobilization networks. Conclusion Prioritizing these contributors and adopting subnational strategies from polio eradication programs to address broader service delivery challenges could improve implementation of integrated, essential primary healthcare services to bolster service delivery and accelerate progress. Achieving UHC is contingent on strengthened subnational service delivery.
... Several countries, especially in Africa, through the help of WHO have embarked on massive free distribution of nets through various means like in antenatal clinics, house-tohouse distribution, markets, schools and in churches. With free distribution campaigns, many countries have seen dramatic increase in ITNs coverage [2]. World Health Organization has been at the forefront of sponsoring the distribution of insecticide treated nets in malaria endemic areas as one of the ways of combating malaria and achieving millennium development goals [3]. ...
Article
Full-text available
Aim: To determine the level, sources of awareness, ownership and utilization of Insecticide Treated Nets (ITNs) by pregnant women, according to age, parity, trimester, occupation and hospital attended. Study Design: The study was a cross sectional survey of 577 randomly selected pregnant women who were attending antenatal clinic in different hospitals in Awka Metropolis, Anambra State, Nigeria. Duration of Study: The study was conducted in February 2016. Materials and Methods: A semi-structured questionnaire was used to obtain information from the study participants. Results: Of a total of 577 respondents, 566(98.1%) had previous knowledge of ITNs while only 11(1.9%) had no prior knowledge. Also, 218(38.5%) had heard about ITNs from Radio, 184(32.5%) from Television, while 374(66.1%) from Antenatal clinics. A total of 217(46.2%) obtained at least one net at antenatal clinic, 39(8.3%) purchased at least one of the ITNs owned, 49(10.4%) received the net at their Local Government Headquarters while 263(66.9%) received at least one by free distribution at other locations. Respondents from government owned Chukwuemeka Odumegwu Ojukwu University Teaching Hospital (COOUTH) had the highest ownership rate of 92.7%, while least 65.0% was observed at the privately owned Divine Hospital and Maternity. The ownership of ITNs was dependent on the hospital as there was a significant difference (X 2 =56.374, df=2, p < .05). Age group 25-34 years had the highest ownership rate of 87.1% while the least 72.8% was in age group 15-24 years. Women in age group 35-44 years had the highest utilization rate of 52.3% while least usage rate was in age group 15-24 years and there was a significant difference (X 2 =7.042, df=2, p < .05). Conclusion: Public health educators, Doctors and Antenatal heads need to do more in sensitization on the importance of utilization of ITNs during pregnancy for protection against malaria vectors.
... against malaria [4][5]. Evidence for the efficacy of LLINs is well known [4][5][6] and in Benin, efforts for their mass distribution are in line with WHO recommendations [7][8][9][10][11][12]. The success of LLINs in malaria prevention is due to the fact that they provide both effective individual protection for users and community protection if net coverage is high enough to reduce vectorial capacity [13]. ...
... The reduced willingness to use the nets was observed despite the fact that nets were distributed free in intense campaigns and sensitizations. This finding agrees with the studies of Thwing et al. (2008) in Niger Republic. It was noted that insecticide treated net given free during bed net distribution campaigns were used for protecting the 'nursery' (waterleaf and small crops) from birds. ...
Article
Full-text available
The abundance and distribution of malaria vectors as well as compliance with the use of Insecticide Treated Nets (ITNs) are key factors in the fight against malaria. Malaria vector species composition, distribution and attitude of residents of Uyo to ITNs were studied. Weekly surveys were conducted in 2018. Anopheles mosquito larvae were collected from the four different axes of the metropolis, reared to adult stage and morphologically identified. Four hundred (400) structured and pre-tested questionnaires were administered to 400 respondents aged 18-70 for their knowledge and compliance with ITNs use [285 (71.25%) females and 115 (28.75%) males]. A total of 689 Anophelines were collected and identified, 289 (42%) males and 400 (58%) females distributed as follows: 182 (26.41%) from Idoro Road, 168 (24.38%) from Use Offot, 145 (21.04%) from Oron Road and 194 (28.15%) from Ikpa Road areas respectively. Anopheles gambiae s.l. made up 98 % (675) while 14 (2%) of the total collections were Anopheles funestus s.l. There was a significant difference in abundance of the two mosquito species in the studied areas (p < 0.05, (0.000); x2 calc=2.41, df =1). More females, 171 (60%) than males 46 (40%), used ITNs although there was no significant difference (p > 0.05), (0.000); 2 = 28.050, df = 1). There was a significant difference (2 = 48.876, df = 1, p = 0.000*) in the usage of ITNs by respondents of different ages. There was no significant difference (2 = 1.265, df = 2, p = 0.531) in ITNs use with household population. Anopheles gambiae s.l. were the major malaria vectors from this study. Poor awareness of the benefits of ITNs was found although many respondents knew about the nets. Public enlightenment on the use and benefits of insecticide treated nets is needed to demystify the negative perceptions of insecticides with which the nets are treated and sustain the gains of the National Malaria Elimination Program.
... Permethrin or deltamethrin or alphacypermethrin treated LLINs provide physical barriers against mosquitoes (malaria vectors) to prevent malaria disease transmission. According to WHO (2005), LLINs proved to be important tools of malaria vectors' control and other vector borne diseases confirmed by several studies in malaria endemic countries in reducing man-vector contact from malaria (Lengeler 2004, Greenwood et al. 2005, Eisele et al. 2006, Thwing et al. 2008. Although, currently the efficacy of pyrethroid insecticides treated LLINs is in doubt due to resistance development by Anopheles mosquites as recently reported in several publications (Protopopoff et al. 2013, Yadouleton et al. 2010. ...
Article
Globally, malaria is one of the major endemic diseases of public health importance caused by Plasmodium spp. and transmitted by Anopheles mosquitoes. Efforts to eradicate malaria disease are on the decline despite appreciable progress recorded in the past. This warranted holistic review of malaria interventions which include among others, the assessment of Long Lasting Insecticidal Treated Nets (LLINs). Adopted questionnaires from Roll Back Malaria (RBM), World Health Organization (WHO) and United Nations Children's Fund (UNICEF) were administered to evaluate ownership levels and utilization rates of LLINs against malaria vectors in urban settlements of Osogbo district, Osun state, Nigeria. Out of 1,500 households surveyed, 78.9% of the households had at least one LLIN, while 78.3% households had the LLINs hanging in their homes, but 60.8% of the households frequently used the LLINs. There were statistically significant differences between the ownership levels of LLINs, usage of LLINs by hanging and the utilization rates of LLINs in the studied population comparatively (p < 0.05). Although the percentage of LLINs possession is high, the rate of utilization of the LLINs varies and is not encouraging which negates the WHO recommended utility procedures. Therefore, acceptability of LLINs usage and sustainable positive attitudinal changes are needed to achieve the target goals of WHO on elimination of the endemic disease.
... Fixed point distribution was used during the pilot phase, but this approach is not suited to the context of the covid-19 pandemic in terms of compliance with barrier measures. A multi country comparison of ITN delivery strategies based on 14 surveys from ve African countries did not nd a signi cant association between delivery strategy and ownership of a net from the campaign [17][18][19][20][21]. ...
Preprint
Full-text available
Background: In 2020, Benin has implemented a digital Insecticide-treated nets (ITNs) mass distribution campaign in the particular context of covid-19 pandemic and then, offered important lessons to share. This paper aims to describe the implementation process as well as the lessons learned and challenges from this campaign. Methods: A descriptive design was used for reporting the planning and implementation process of ITNs campaign. Moreover, the changes and adaptations related to covid-19 pandemic are well described. Results: A total of 3,175,773 households were registered corresponding to a total of 14,423,998 persons (13.55% more from projection). Moreover, 94.16 % (13,581,637 people) of enumerated population were protected. A total of 7,652,166 ITNs were distributed countrywide. Conclusions: High political commitment, engagement and support add to the financial and technical supports from partners were the essential factors that make 2020 ITNs mass campaign success in Benin despite the particular context of COVID-19 pandemic. It is essential to maintain the prevention activities for malaria and this could substantially reduce the overall impact of the COVID-19 pandemic in the populations at malaria risk.
... against malaria [4][5]. Evidence for the efficacy of LLINs is well known [4][5][6] and in Benin, efforts for their mass distribution are in line with WHO recommendations [7][8][9][10][11][12]. The success of LLINs in malaria prevention is due to the fact that they provide both effective individual protection for users and community protection if net coverage is high enough to reduce vectorial capacity [13]. ...
Article
Full-text available
Malaria is a disease declared by WHO as a public health problem in developing countries It is a parasitic infection of erythrocytes by a protozoan of the genus Plasmodium transmitted by the bites of female Anopheles mosquitoes. The risk of contracting this disease does not spare any section of the population. This study aims to assess the impact of behavioral changes in the population prone to malaria disease after having implemented preventive strategies such as solid awareness and training in repairing mosquito nets. This is a cross-sectional study conducted from April to June 2017 among children under five years of age whose parents had previously (2 years before) received nets followed by sensitization for better use (cluster 1: 115) plus LLIN repair kits (cluster 2: 121) or none at all (cluster 3 control: 137). Children were randomly selected. Thick and thin blood smears were produced on the same slide according to WHO protocols, hemoglobin was read on Hemoreader equipment and RDTs were also performed. A total of 373 children were examined and sampled. Overall prevalence of anemia was 60%. The overall prevalence of anemia was 60% with no significant difference between the three clusters (p>0.05). Out of 373 slides read by microscopy, 19.3% showed P. falciparum and no others species was identified. The prevalence of malaria in Group 1, cluster 2 and cluster 3 was 22.6%, 4.9% and 29.9% respectively (p<0.001). Awareness more repair kits are probably at the root of the low rate of parasitized children in cluster 2 (p<0.001). This assessment showed a low prevalence of parasitaemia in children whose parents received LLINs and repair kits and were sensitized to better use. The National Malaria Control Program (NMCP) should be more involved in raising awareness of behavior change for better net use.
... Fixed point distribution was used during the pilot phase, but this approach was not suited in the context of the COVID-19 pandemic, in terms of compliance with barrier measures. A multi-country comparison of ITN delivery strategies based on 14 surveys from ve African countries did not nd a signi cant association between delivery strategy and ownership of a net from the campaign [17][18][19][20][21]. ...
Preprint
Full-text available
Background: In 2020, Benin has implemented a digitalized mass distribution campaign of insecticide-treated nets (ITNs) in the particular context of COVID-19 pandemic. This paper describes the implementation process as well as the challenges and lessons learned from this campaign. Methods: A descriptive design was used for reporting the planning and implementation process of ITNs campaign. Moreover, the changes and adaptations related to COVID-19 pandemic are described. Results: A total of 3,175,773 households were registered corresponding to a total of 14,423,998 persons (13.55% more from projection). Moreover, 94.16 % (13,581,637 people) of enumerated population were protected. A total of 7,652,166 ITNs were distributed countrywide. Conclusions: High political commitment, engagement and support add to the financial and technical supports from partners were the essential factors that make 2020 ITNs mass campaign success in Benin despite the particular context of COVID-19 pandemic. It is essential to maintain the prevention activities for malaria and this could substantially reduce the overall impact of the COVID-19 pandemic for the populations at malaria risk.
... CHV and MC demonstrated relatively low inequity in favour of the least-poor households, with very similar C. Ind values and overlapping confidence intervals. Our results may seem contrary to other studies which have found that MCs reduce inequity [19,35,[37][38][39]. However, different baseline levels of coverage and inequity might explain this; it is easier to reduce inequity from a baseline of low coverage and high inequity relative to one of higher coverage and lower inequity. ...
Article
Full-text available
Background Malaria-endemic countries distribute long-lasting insecticidal nets (LLINs) through combined channels with ambitious, universal coverage (UC) targets. Kenya has used eight channels with variable results. To inform national decision-makers, this two-arm study compares coverage (effects), costs, cost-effectiveness, and equity of two combinations of LLIN distribution channels in Kenya. Methods Two combinations of five delivery channels were compared as ‘intervention’ and ‘control’ arms. The intervention arm comprised four channels: community health volunteer (CHV), antenatal and child health clinics (ANCC), social marketing (SM) and commercial outlets (CO). The control arm consisted of the intervention arm channels except mass campaign (MC) replaced CHV. Primary analysis used random sample household survey data, service-provider costs, and voucher or LLIN distribution data to compare between-arm effects, costs, cost-effectiveness, and equity. Secondary analyses compared costs and equity by channel. Results The multiple distribution channels used in both arms of the study achieved high LLIN ownership and use. The intervention arm had significantly lower reported LLIN use the night before the survey (84·8% [95% CI 83·0–86·4%] versus 89·2% [95% CI 87·8–90·5%], p < 0·0001), higher unit costs ($10·56 versus $7·17), was less cost-effective ($86·44, 95% range $75·77–$102·77 versus $69·20, 95% range $63·66–$77·23) and more inequitable (Concentration index [C.Ind] = 0·076 [95% CI 0·057 to 0·095 versus C.Ind = 0.049 [95% CI 0·030 to 0·067]) than the control arm. Unit cost per LLIN distributed was lowest for MC ($3·10) followed by CHV ($10·81) with both channels being moderately inequitable in favour of least-poor households. Conclusion In line with best practices, the multiple distribution channel model achieved high LLIN ownership and use in this Kenyan study setting. The control-arm combination, which included MC, was the most cost-effective way to increase UC at household level. Mass campaigns, combined with continuous distribution channels, are an effective and cost-effective way to achieve UC in Kenya. The findings are relevant to other countries and donors seeking to optimise LLIN distribution. Trial registration The assignment of the intervention was not at the discretion of the investigators; therefore, this study did not require registration.
... Fixed point distribution was used during the pilot phase, but this approach was not suited in the context of the COVID-19 pandemic, in terms of compliance with barrier measures. A multi-country comparison of ITN delivery strategies based on 14 surveys from five African countries did not find a significant association between delivery strategy and ownership of a net from the campaign [17][18][19][20][21]. ...
Article
Full-text available
Background In 2020, Benin has implemented a digitalized mass distribution campaign of insecticide-treated nets (ITNs) in the particular context of COVID-19 pandemic. This paper describes the implementation process as well as the challenges and lessons learned from this campaign. Methods A descriptive design was used for reporting the planning and implementation process of ITNs campaign. Moreover, the changes and adaptations related to COVID-19 pandemic are described. Results A total of 3,175,773 households were registered corresponding to a total of 14,423,998 persons (13.55% more from projection). Moreover, 94.16% (13,581,637 people) of enumerated population were protected. A total of 7,652,166 ITNs were distributed countrywide. Conclusions High political commitment, engagement and support add to the financial and technical supports from partners were the essential factors that make 2020 ITNs mass campaign success in Benin despite the particular context of COVID-19 pandemic. It is essential to maintain the prevention activities for malaria and this could substantially reduce the overall impact of the COVID-19 pandemic for the populations at malaria risk.
... Permethrin or deltamethrin or alphacypermethrin treated LLINs provide physical barriers against mosquitoes (malaria vectors) to prevent malaria disease transmission. According to WHO (2005), LLINs proved to be important tools of malaria vectors' control and other vector borne diseases confirmed by several studies in malaria endemic countries in reducing man-vector contact from malaria (Lengeler 2004, Greenwood et al. 2005, Eisele et al. 2006, Thwing et al. 2008. Although, currently the efficacy of pyrethroid insecticides treated LLINs is in doubt due to resistance development by Anopheles mosquites as recently reported in several publications (Protopopoff et al. 2013, Yadouleton et al. 2010. ...
Preprint
Globally, malaria is one of the major endemic diseases of public health importance caused by Plasmodium spp. and transmitted by Anopheles mosquitoes. Efforts to eradicate malaria disease are on the decline despite appreciable progress recorded in the past. This warranted holistic review of malaria interventions which include among others, the assessment of Long Lasting Insecticidal Treated Nets (LLINs). Adopted questionnaires from Roll Back Malaria (RBM), World Health Organization (WHO) and United Nations Children's Fund (UNICEF) were administered to evaluate ownership levels and utilization rates of LLINs against malaria vectors in urban settlements of Osogbo district, Osun state, Nigeria. Out of 1,500 households surveyed, 78.9% of the households had at least one LLIN, while 78.3% households had the LLINs hanging in their homes, but 60.8% of the households frequently used the LLINs. There were statistically significant differences between the ownership levels of LLINs, usage of LLINs by hanging and the utilization rates of LLINs in the studied population comparatively (p < 0.05). Although the percentage of LLINs possession is high, the rate of utilization of the LLINs varies and is not encouraging which negates the WHO recommended utility procedures. Therefore, acceptability of LLINs usage and sustainable positive attitudinal changes are needed to achieve the target goals of WHO on elimination of the endemic disease.
... Fixed point distribution was used during the pilot phase, but this approach is not suited to the context of the covid-19 pandemic in terms of compliance with barrier measures. A multi country comparison of ITN delivery strategies based on 14 surveys from ve African countries did not nd a signi cant association between delivery strategy and ownership of a net from the campaign [17][18][19][20][21]. ...
Preprint
Full-text available
Background In 2020, Benin has implemented a digital Insecticide-treated nets (ITNs) mass distribution campaign in the particular context of covid-19 pandemic and then, offered important lessons to share. This paper aims to describe the implementation process as well as the lessons learned and challenges from this campaign. Methods A descriptive design was used for reporting the planning and implementation process of ITNs campaign. Moreover, the changes and adaptations related to covid-19 pandemic are well described. Results A total of 3,175,773 households were registered corresponding to a total of 14,423,998 persons (13.55% more from projection). Moreover, 94.16% (13,581,637 people) of enumerated population were protected. A total of 7,652,166 ITNs were distributed countrywide. Conclusions High political commitment, engagement and support add to the financial and technical supports from partners were the essential factors that make 2020 ITNs mass campaign success in Benin despite the particular context of COVID-19 pandemic. It is essential to maintain the prevention activities for malaria and this could substantially reduce the overall impact of the COVID-19 pandemic in the populations at malaria risk.
... This is comparable to findings in studies done in Ghana [5] and Abia [47]. In a study done in a rural community in Enugu [41] [54]. In another survey in Sri Lanka, 75% ITN use was recorded during dry season compared to 90% during rainy season. ...
... The WHO recommends that to achieve and maintain universal ITN coverage, countries should apply a combination of mass and continuous distributions through multiple channels, including ANC and EPI [7]. Mass distributions have been identified as an excellent tool for "catch-up"-if carried out efficiently and successfully they are able to rapidly and efficiently increase coverage and usage of nets on a large scale [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22]. Equity (i.e. ...
Article
Full-text available
Background: Insecticide-treated nets (ITNs) are one of the most cost-effective measures for preventing malaria. The World Health Organization recommends both large-scale mass distribution campaigns and continuous distributions (CD) as part of a multifaceted strategy to achieve and sustain universal access to ITNs. A combination of these strategies has been effective for scaling up ITN access. For policy makers to make informed decisions on how to efficiently implement CD or combined strategies, information on the costs and cost-effectiveness of these delivery systems is necessary, but relatively few published studies of the cost continuous distribution systems exist. Methods: To address the gap in continuous distribution cost data, four types of delivery systems-CD through antenatal care services (ANC) and the expanded programme on immunization (EPI) (Ghana, Mali, and mainland Tanzania), CD through schools (Ghana and mainland Tanzania), and a combined community/health facility-based distribution (Zanzibar, Tanzania), as well as mass distributions (Mali)-were costed. Data on costs were collected retrospectively from financial and operational records, stakeholder interviews, and resource use surveys. Results: Overall, from a full provider perspective, mass distributions and continuous systems delivered ITNs at overlapping economic costs per net distributed (mass distributions: 4.37-4.61 USD, CD channels: 3.56-9.90 USD), with two of the school-based systems and the mass distributions at the lower end of this range. From the perspective of international donors, the costs of the CD systems were, for the most part, less costly than the mass distributions (mass distributions: 4.34-4.55 USD, Ghana and Tanzania 2017 school-based: 3.30-3.69 USD, health facility-based: 3.90-4.55 USD, combined community/health facility 4.55 USD). The 2015 school-based distribution (7.30 USD) and 2016 health facility-based distribution (6.52 USD) programmes in Tanzania were an exception. Mass distributions were more heavily financed by donors, while CD relied more extensively on domestic resource contributions. Conclusions: These results suggest that CD strategies can continue to deliver nets at a comparable cost to mass distributions, especially from the perspective of the donor.
... Social barriers have also been shown to impact coverage such as when sleeping in public spaces, a problem in scenarios such as large religious gatherings or journeys (Monroe et al., 2014). A lack of education regarding transmission of malaria in some cases can also lead to low coverage rates, with users either ignorant of the mosquito vector, perceiving malaria to be low risk, few mosquitoes to be present, or for the net to be no longer useful if the insecticide has lost efficacy (Baume, Reithinger & Woldehanna, 2009;Pulford et al., 2011;Thwing et al., 2008). This ultimate rate of coverage may also be seen to be impacted by longevity of nets and motivations to wash dirty nets or repair minor tears and holes, and therefore the barriers to this also affect use (Toé et al., 2009). ...
... 10 In response to Bermejo and Veeken, perhaps, studies associated with the early ITN trials demonstrated important links between seasonal variation in vector abundance and perceived malaria risk in Tanzania 11 ; in Benin, Ghana, and the Gambia, associations were observed between vector abundance and ITN use, [12][13][14] although not always directly related to season. In the mass campaign era, increases in ITN use by children aged less than 5 years were observed in Niger from 15% (first post-campaign dry season) to 55% (first post-campaign rainy season), 15 from 44% to 53% in Togo, 16 from 66% to 98% in Burkina Faso, 17 from 31% to 73% in Benin, 18 and from 55% to 74% in Zambia. 19 The implications for survey fieldwork timing have also been noted, 20 with a mean ITN use:access ratio of 0.91 for Malaria Indicator Surveys (MISs) and 0.78 for Demographic and Health Surveys (DHSs), as DHSs are primarily carried out in the dry season, whereas MISs are fielded in the peak transmission season after the rainy season. ...
Article
Full-text available
Seasonal variation in the proportion of the population using an insecticide-treated net (ITN) is well documented and is widely believed to be dependent on mosquito abundance and heat, driven by rainfall and temperature. However, seasonal variation in ITN use has not been quantified controlling for ITN access. Demographic and Health Survey and Malaria Indicator Survey datasets, their georeferenced data, and public rainfall and climate layers were pooled for 21 countries. Nine rainfall typologies were developed from rainfall patterns in Köppen climate zones. For each typology, the odds of ITN use among individuals with access to an ITN within their households ("ITN use given access") were estimated for each month of the year, controlling for region, wealth quintile, residence, year, temperature, and malaria parasitemia level. Seasonality of ITN use given access was observed over all nine rainfall typologies and was most pronounced in arid climates and less pronounced where rainfall was relatively constant throughout the year. Peak ITN use occurred 1-3 months after peak rainfall and corresponded with peak malaria incidence and average malaria transmission season. The observed lags between peak rainfall and peak ITN use given access suggest that net use is triggered by mosquito density. In equatorial areas, ITN use is likely to be high year-round, given the presence of mosquitoes and an associated year-round perceived malaria risk. These results can be used to inform behavior change interventions to improve ITN use in specific times of the year and to inform geospatial models of the impact of ITNs on transmission.
... Among those living in urban settings, more than 75% are in the top two wealth quintiles [4]. Analogous to other countries with a high malaria burden, to help increase ITN ownership across these households, the NMEP employed free ITN distribution [12,15,[31][32][33]. This has led to households in both the lowest wealth quintiles and in rural areas having higher ITN ownership [3]. ...
Article
Full-text available
Background To reduce the malaria burden in Nigeria, the country is scaling up prevention and treatment interventions, especially household ownership and use of insecticide-treated nets (ITNs). Nevertheless, large gaps remain to achieve the goals of the National Malaria Strategic Plan 2014–2020 of universal access to ITNs and their increased use. To inform the targeting of intervention strategies and to maximize impact, the authors conducted a sub-national profiling of household ITN ownership and use in the general population to identify key predictors of ITN ownership and use, and the sub-groups that are at higher risk of low ITN coverage and use. Methods The authors conducted a secondary analysis of data from the 2015 Nigeria Malaria Indicator Survey. Using the Chi square automatic interaction detector (CHAID) and multiple logistic regression analysis, the authors examined the key predictors of ITN ownership and use in the general population throughout Nigeria. Results The CHAID models identified region of the country as the best predictor of household ownership of at least one ITN and its use in the general population, with higher ownership and use observed in the northern regions. The odds of a household owning an ITN were five times greater in the North West region compared with the North Central region (odds ratio [OR] = 5.47, 95% confidence interval [CI] 4.46–6.72, p < 0.001). The odds of ITN use were two times greater for those living in the North West region compared with the North Central region (OR = 2.04, 95% CI 1.73–2.41, p < 0.001). Other significant predictors were household size, head of household education level, household wealth quintile, and place of residence. The CHAID gain index results identified households in the South West, North Central and South Central regions with low ITN ownership, and the general population in the South South, South East and North Central regions with low ITN use. Conclusions This study reveals regional differences in ITN ownership and use in Nigeria. Therefore, the findings from this analysis provide evidence that could inform the NMEP to better target future campaign and routine distribution of ITNs, to achieve universal access and increased use by 2020 in Nigeria.
... The outcome of awareness of LLIN in this study is in agreement with 95.3% obtained in Ekiti State in mass predistribution campaign in 2014 [10] and 97.9% reported from Oyo state. Similar trend was also reported from regions outside Nigeria [11,12]. This corroborates the impact of campaign on LLINs coverage and the need to maintain such strategy in sustaining the progress recorded [13]. ...
Article
Full-text available
Vector control with long-lasting insecticide treated nets (LLINs) has been identified as a major component of malaria prevention and control. The study examined present status of awareness, ownership, and utilization of LLINs in malaria high-risk areas of Ekiti State, Nigeria. Data were obtained from 352 copies of semistructured interviewer-guided questionnaire distributed to participants of each household in the four Local Government Areas (LGAs) of Ekiti State, where malaria is endemic after mass distribution of LLINs. Findings in this study showed that awareness was high (91.8%) in the Local Government Areas (LGAs) with mass media contributing largely (44.3%) to awareness. Also, LLINs ownership was found to be high (71.3%) with 72.9% of the nets being supplied by the government. Of the owners of LLINs, usage rate was observed to be 67.6%. Multivariate analysis result showed that statistically significant sociodemographic characteristics of respondents predicting the usage of LLINs included age greater than 50 years (p value = 0.008), female gender ( χ2 = 8.2014, p value = 0.004), being married ( χ2 = 24.721, p value <0.001), civil servants ( χ2 = 12.739, p value = 0.005), and average income above poverty line ( χ2 = 13.576, p value = 0.004). The study concluded that although not all households surveyed owned LLINs, nevertheless, the level of usage of LLINs among net-owning households was high. The study recommended continuous free distribution, periodic household survey, and expanding public knowledge on the benefits of LLINs usage especially through social media.
... Typically, MIS is conducted during/at the end of rainy season while the DHS can be done any season. Given that ITN use is higher in the rainy season and immediately thereafter when malaria transmission is at a peak [28,29], ITN use is higher in MIS survey countries than in DHS countries. Also, the timing of the most recent ITN mass campaigns was not accounted for in the analysis. ...
Article
Full-text available
Background The degree to which insecticide-treated net (ITN) supply accounts for age and gender disparities in ITN use among household members is unknown. This study explores the role of household ITN supply in the variation in ITN use among household members in sub-Saharan Africa. Methods Data was from Malaria Indicator Surveys or Demographic and Health Surveys collected between 2011 and 2016 from 29 countries in sub-Saharan Africa. The main outcome was ITN use the previous night. Other key variables included ITN supply (nets/household members), age and gender of household members. Analytical methods included logistic regressions and meta-regression. Results Across countries, the median (range) of the percentage of households with enough ITNs was 30.7% (8.5–62.0%). Crude analysis showed a sinusoidal pattern in ITN use across age groups of household members, peaking at 0–4 years and again around 30–40 years and dipping among people between 5–14 and 50+ years. This sinusoidal pattern was more pronounced in households with not enough ITNs compared to those with enough ITNs. ITN use tended to be higher in females than males in households with not enough ITNs while use was comparable among females and males in households with enough ITNs. After adjusting for wealth quintile, residence and region, among households with not enough ITNs in all countries, the odds of ITN use were consistently higher among children under 5 years and non-pregnant women 15–49 years. Meta-regressions showed that across all countries, the mean adjusted odds ratio (aOR) of ITN use among children under 5 years, pregnant and non-pregnant women aged 15–49 years and people 50 years and above was significantly higher than among men aged 15–49 years. Among these household members, the relationship was attenuated when there were enough ITNs in the household (dropping 0.26–0.59 points) after adjusting for geographical zone, household ITN supply, population ITN access, and ITN use:access ratio. There was no significant difference in mean aOR of ITN use among school-aged children compared to men aged 15–49 years, regardless of household ITN supply. Conclusions This study demonstrated that having enough ITNs in the household increases level of use and decreases existing disparities between age and gender groups. ITN distribution via mass campaigns and continuous distribution channels should be enhanced as needed to ensure that households have enough ITNs for all members, including men and school-aged children.
... The effects of malaria are especially strong among pregnant women, for whom malaria may cause maternal anaemia, preterm delivery, and low birthweight [2][3][4]. High ITN coverage in sub-Saharan Africa has been reported; however, discrepancies in ITN use in the region remain problematic [5][6][7]. ...
Article
Full-text available
Background This study aimed to identify factors at individual and community level influencing insecticide-treated net (ITN) usage among groups of women of childbearing age (WOCBA) in Malawi. Methods Factors influencing ITN usage in Malawi were assessed through interviews with 16,130 WOCBA (15–49 years) across 850 communities who participated in the 2015–2016 Malawi Demographic Health Survey. Multilevel logistic regression analysis was used. Results ITN use was similar between pregnant women and non-pregnant women with children under 5 years (45.9% and 46.9%, respectively), but slightly lower among non-pregnant women without children under 5 years (39.1%). Both individual and community characteristics were associated with ITN use among WOCBA and varied significantly across subgroups. Specifically, non-pregnant women with children under 5 years living in communities where women had high autonomy in health care decisions had an 18% greater odds of using an ITN compared with those from communities where women had low health care autonomy (adjusted odds ratio [aOR] = 1.18; 95% confidence interval [CI] 1.00–1.38). Distance to health care facility influenced ITN usage among pregnant women; those who did not regard distance as a problem had a 44% greater odds of using an ITN than those for whom distance was seen as a problem (aOR = 1.44; 95% CI 1.09–1.89). Number of household members, region, urbanization, and community ITN coverage influenced ITN usage across all WOCBA groups. Conclusion The findings confirmed the importance of assessing various factors affecting ITN usage among groups of WOCBA. Both individual- and community-level factors should be considered when designing and implementing ITN programmes in Malawi.
... A core focus of free mosquito bed net distribution campaigns has been equitable coverage within and between populations-with the goal of reducing disparities in access to preventive methods for economically or socially disadvantaged sub-populations. Previous studies show that large-scale, free net distribution campaigns can reduce inequities in household net ownership across socio-economic gradients [14,15]. On the demand-side, much attention has been paid to the need for subsidization of the cost (or free) of bed nets as a means to increase bed net coverage, because cost has been identified as an important barrier to bed net ownership [16]. ...
Article
Full-text available
Background While the distribution of mosquito bed nets is a widely adopted approach for malaria prevention, studies exploring how the usage of a net may be influenced by its source and other factors remain sparse. Methods A standardized questionnaire and home-visit observations were used to collect data from 9 villages in Budondo sub-county, Uganda in 2016. Household- and individual-level data were collected, such as bed net ownership (at least one net versus none), acquirement source (free versus purchased), demographics, as well as knowledge of malaria and preventative measures. Net-level data, including alternative uses, and bed net quantity and integrity, were also collected. Mixed effects logistic regression models were performed to identify the key determinants of bed net use. Results Overall, the proportion of households with at least one bed net was 40%, while bed net availability was only reported among 27% of all household members. Awareness of the benefits of bed net use was statistically significantly associated with ownership of at least one net (OR = 1.72, 95% CI 1.11–2.68, p = 0.02). Among those who own net(s), the odds of a bed net being correctly used (i.e., to sleep under) after adjusting for potential confounders were significantly lower for nets that were obtained free compared to nets that were purchased by the owners themselves (OR = 0.33, 95% CI 0.21–0.51, p < 0.01), resulting in an alternative use of the net. Other factors such as female gender, children ≤ 5 years old, and pregnancy status were also significantly associated with having a net to sleep under (all p < 0.01). Conclusion Understanding inter- and intra-household net-use factors will help malaria control programmes more effectively direct their efforts to increase public health impact. Future studies may additionally consider socioeconomic status and track the lifetime of the net.
... Recently, Taylor et al. [24] showed that ownership of mosquito nets increased in Burkina Faso from 6% in 2003 to 57% in 2010. Similarly, in Niger, ownership in- creased to 65.1% in all households and to 74.6% in house- holds with children under 5; however, the authors found that only 33% of people had slept under their mosquito net the night before the survey [25]. On the other hand, a robust use of mosquito control tools (long lasting insecti- cide impregnated nets, mosquito coils, insecticide sprays) could lead to a change in the vector biting behaviour. ...
Article
Full-text available
Background: Urbanization is a main trend in developing countries and leads to health transition. Although non-communicable diseases are increasing in cities of low-income countries, vector-borne diseases such as malaria, are still present. In the case of malaria, transmission is lower than in rural areas, but is uneven and not well documented. In this study, we wanted to evaluate intra-urban malaria transmission in a West African country (Burkina Faso). Methods: A cross-sectional study on 847 adults (35 to 59 year-old) and 881 children (6 months to 5 year-old) living in 1045 households of four districts (Dogona, Yeguere, Tounouma and Secteur 25) of Bobo-Dioulasso was performed between October and November 2013. The districts were selected according to a geographical approach that took into account the city heterogeneity. Malaria prevalence was evaluated using thick and thin blood smears. Human exposure to Anopheles bites was measured by assessing the level of IgG against the Anopheles gSG6-P1 salivary peptide. Adult mosquitoes were collected using CDC traps and indoor insecticide spraying in some houses of the four neighbourhoods. The Anopheles species and Plasmodium falciparum infection rate were determined using PCR assays. Results: In this study, 98.5% of the malaria infections were due to Plasmodium falciparum. Malaria transmission occurred in the four districts. Malaria prevalence was higher in children than in adults (19.2 vs 4.4%), and higher in the central districts than in the peripheral ones (P = 0.001). The median IgG level was more elevated in P. falciparum-infected than in non-infected individuals (P < 0.001). Anopheles arabiensis was the main vector identified (83.2%; 227 of the 273 tested mosquito specimens). Five P. falciparum-infected mosquitoes were caught, and they were all caught in the central district of Tounouma where 28.6% (14/49) of the tested blood-fed mosquito specimens had a human blood meal. Conclusions: This study showed that urban malaria transmission occurred in Bobo-Dioulasso, in all the four studied areas, but mainly in central districts. Environmental determinants primarily explain this situation, which calls for better urban management.
... Insecticide-treated nets (ITN) are an important tool for preventing malaria-related morbidity and mortality, estimated to be responsible for 68% of the over 600 million cases averted since 2000 [1]. Most ITNs have been distributed through mass campaigns, which have been shown to increase coverage rapidly and equitably [2][3][4][5][6][7][8][9][10][11][12][13][14]. However, births, migration, and ITN damage erode coverage gains and require repeated or ongoing inputs of new ITNs. ...
Article
Full-text available
Background Insecticide-treated nets are a key intervention for malaria prevention. While mass distribution can rapidly scale up ITN coverage, multiple channels may be needed to sustain high levels of ITN access and ownership. In Ghana’s Eastern Region, a continuous ITN distribution pilot, started in October 2012, 18–24 months after a mass campaign. The pilot distributed ITNs through antenatal care services (ANC), child welfare clinic services (CWC) through the Expanded Programme on Immunization, and to students in two classes of primary schools. Methods ITN ownership and access were evaluated through two cross-sectional surveys, conducted at baseline in April 2012, 11–15 months after the mass campaign, and at endline in December 2013, after 1 year of continuous distribution. A representative sample was obtained using a multi-stage cluster sampling design. Household heads were interviewed using a structured questionnaire. Results Household ownership of at least one ITN was 91.3% (95% CI 88.8–93.9) at baseline and was not statistically significant at endline 18 months later at 88.3% (95% CI 84.9–91.0) (p = 0.10). Ownership of at least 1 ITN per two people significantly decreased from 51.3% (95% CI 47.1–55.4) to 40.2% (95% CI 36.4–44.6) (p < 0.01). Population access to an ITN within the household also significantly decreased from 74.5% (95% CI 71.2–77.7) at baseline to 66.4% (95% CI 62.9–69.9) at endline (p < 0.01). The concentration index score for any CD channel was slightly positive (0.10; 95% CI 0.04–0.15). Conclusion Thirty-one months after the mass campaign, the 15 months of continuous distribution activities had maintained levels of household ownership at least one ITN, but household ownership of one ITN for every two people and population access to ITN had declined. Ownership and access were higher with the CD programme than without. However, the number of ITNs delivered via ANC, CWC and two primary school classes were insufficient to sustain coverage targets. Future programmes should implement continuous distribution strategies fully within 1 year after a campaign or widen eligibility criteria (such as increase the number of classes) during the first year of implementation to make up for programme delays.
... Although, the mass campaign exercise was to a great extent a successful one, based on the WHO indicators, it is important to note that there was a higher percentage of the population that could access an LLIN (ninety-one percent) as compared to the lesser proportion that used one (eighty-two percent), a finding that has been previously reported in other studies [20][21][22][23]. This is an indication that there still exists behavioral change gaps and challenges affecting LLIN usage in this setting. ...
Article
Full-text available
Introduction: Uganda is conducting a second mass LLIN distribution campaign and Katakwi district recently received LLINs as part of this activity. This study was conducted to measure the success of the campaign in this setting, an area of high transmission, with the objectives to estimate LLIN ownership, access and use pre and post campaign implementation. Methods: Two identical cross sectional surveys, based on the Malaria Indicator Survey methodology, were conducted in three sub-counties in this district (Kapujan, Magoro and Toroma), six months apart, one before and another after the mass distribution campaign. Data on three main LLIN indicators including; household LLIN ownership, population with access to an LLIN and use were collected using a household and a women's questionnaire identical to the Malaria Indicator Survey. Results: A total of 601 and 607 households were randomly selected in survey one and two respectively. At baseline, 60.57% (56.53-64.50) of households owned at least one net for every two persons who stayed in the household the night before the survey which significantly increased to 70.35% (66.54-73.96) after the campaign (p = 0.001). Similarly, the percentage of the household population with access to an LLIN significantly increased from 84.76% (82.99-86.52) to 91.57% (90.33-92.81), p = 0.001 and the percentage of household population that slept under an LLIN the night before the survey also significantly increased from 56.85% (55.06-58.82) to 81.72% (76.75-83.21), p = 0.001. Conclusion: The LLIN mass campaign successfully achieved the national target of over eighty-five percent of the population with access to an LLIN in this setting, however, universal household coverage and use were fourteen and three percent points less than the national target respectively. This is useful for malaria programs to consider during the planning of future campaigns by tailoring efforts around deficient areas like mechanisms to increase universal coverage and behavior change communication.
... Survey teams administered a detailed questionnaire to each household following a standard format similar to those used LLIN coverage surveys elsewhere [8][9][10]. Household members, bednets, and sleeping spaces were inventoried. ...
Article
Full-text available
Background Madagascar conducted the first two phases of a national free mass distribution campaign of long-lasting insecticidal nets (LLINs) during a political crisis in 2009 aiming to achieve coverage of two LLINs per household as part of the National Malaria Control Strategy. The campaign targeted households in 19 out of 91 total health districts. Methods A community-based cross-sectional household survey using a three-stage cluster sample design was conducted four months post campaign to assess LLIN ownership, access and use. Multivariable logistic regression analysis was used to identify factors associated with household LLIN access and individual LLIN use. Results A total of 2211 households were surveyed representing 8867 people. At least one LLIN was present in 93.5% (95% confidence interval [CI], 91.6–95.5%) of households and 74.8% (95% CI, 71.0–78.6%) owned at least two LLINs. Access measured as the proportion of the population that could potentially be covered by household-owned LLINs was 77.2% (77.2% (95% CI, 72.9–81.3%) and LLIN use by all individuals was 84.2% (95% CI, 81.2–87.2%). LLIN use was associated with knowledge of insecticide treated net use to prevent malaria (OR = 3.58, 95% CI, 1.85–6.94), household ownership of more LLINs (OR 2.82, 95% CI 1.85–4.3), presence of children under five (OR = 2.05, 95% CI, 1.67–2.51), having traveled to the distribution point and receiving information about hanging a bednet (OR = 1.56, 95% CI, 1.41–1.74), and having received a post-campaign visit by a community mobilizer (OR = 1.75, 95% CI, 1.26–2.43). Lower LLIN use was associated with increasing household size (OR = 0.81 95% CI 0.77–0.85) and number of sleeping spaces (OR = 0.55, 95% CI, 0.44–0.68). Conclusions A large scale free mass LLIN distribution campaign was feasible and effective at achieving high LLIN access and use in Madagascar. Campaign process indicators highlighted potential areas for strengthening implementation to optimize access and equity.
... The distribution of long-lasting, insecticide-treated nets (ITNs) is a recognized tool for reducing the transmission of malaria in malaria-endemic countries. Initial distributions focused on vulnerable pregnant women and children under 5 years old to reduce mortality, using distribution through antenatal and vaccination clinics [1][2][3][4][5], social marketing [6][7][8] and targeted mass campaigns [9][10][11][12][13][14][15][16][17][18]. Since WHO's call for universal ITN coverage [19], over 1 billion ITNs have been distributed through mass campaigns [20], generally implemented every 3 years, which replaces all existing ITNs as accounting for existing ITNs in households is not operationally practical [21]. ...
Article
Full-text available
Background: Continuous distribution of insecticide-treated nets (ITNs) is thought to be an effective mechanism to maintain ITN ownership and access between or in the absence of mass campaigns, but evidence is limited. A community-based ITN distribution pilot was implemented and evaluated in Toamasina II District, Madagascar, to assess this new channel for continuous ITN distribution. Methods: Beginning 9 months after the December 2012 mass campaign, a community-based distribution pilot ran for an additional 9 months, from September 2013 to June 2014. Households requested ITN coupons from community agents in their village. After verification by the agents, households exchanged the coupon for an ITN at a distribution point. The evaluation was a two-stage cluster survey with a sample size of 1125 households. Counterfactual ITN ownership and access were calculated by excluding ITNs received through the community pilot. Results: At the end of the pilot, household ownership of any ITN was 96.5%, population access to ITN was 81.5 and 61.5% of households owned at least 1 ITN for every 2 people. Without the ITNs provided through the community channel, household ownership of any ITN was estimated at 74.6%, population access to an ITN at 55.5%, and households that owned at least 1 ITN for 2 people at only 34.7%, 18 months after the 2012 campaign. Ownership of community-distributed ITNs was higher among the poorest wealth quintiles. Over 80% of respondents felt the community scheme was fair and simple to use. Conclusions: Household ITN ownership and population ITN access exceeded RBM targets after the 9-month community distribution pilot. The pilot successfully provided coupons and ITNs to households requesting them, particularly for the least poor wealth quintiles, and the scheme was well-perceived by communities. Further research is needed to determine whether community-based distribution can sustain ITN ownership and access over the long term, how continuous availability of ITNs affects household net replacement behaviour, and whether community-based distribution is cost-effective when combined with mass campaigns, or if used with other continuous channels instead of mass campaigns.
... Resultantly, WHO now recommends including hang-up campaigns by community volunteers as part of LLIN distribution campaigns [8]. However, the impact of post-campaign visits on ITN use has been debated, with published literature from various countries in sub-Saharan Africa finding no significant impact in use following visits [17,[26][27][28]. However, this study has indicated that the campaign was critical in the study population being exposed to net-related information. ...
Article
Full-text available
Background Mass distribution campaigns of insecticide-treated nets for malaria prevention are usually accompanied by intensive behaviour change communication (BCC) to encourage hanging and use of nets. However, data on the effectiveness of these communication efforts are scarce. In preparation for the next round of mass campaigns in Nigeria, a secondary analysis of existing data from post-campaign surveys was undertaken to investigate the influence of BCC on net hanging and use. Methods Surveys were undertaken between 2009 and 2012 in ten states in Nigeria using standardized questionnaires. Two-stage cluster sampling was used to select households in each study site. Outcomes were defined as the effects of BCC message exposure and recall on knowledge, attitudes, perception as well as intentions and actual use. From the univariable analysis, potential confounders and explanatory variables were identified and key effects explored in multivariable linear or logistic regression models; terms in the models were kept if they had a marginal significance with p < 0.2. To quantify the effects from BCC, a treatment effect model was used with an inverse-probability weight regression adjustment. ResultsMore than half of the respondents (58.4 %; 95 % CI 56.0, 60.7) had heard a message about net use or hanging during or after the distribution campaign, with media cited as the most common source of information. Attitude towards net use was positively linked to the number of messages recalled and was overall better in the northern study sites. The number of messages recalled was also the strongest predictor of knowledge (p < 0.001). All BCC outcomes showed a significant increase in net use, which was strongest for the confidence to take action regarding nets with an overall effect of 17 %-point increase of net use comparing poor and excellent confidence levels. Intention to use every night increased net use by 15 %-points and discussing net use in the family by 8 % points. All these effects were statistically significant (p < 0.001). Conclusions Multichannel BCC campaigns as well as other media were effective in contributing to an increase in net culture, hanging and use, particularly by vulnerable groups.
... To this end, Liberia carried out a universal coverage campaign in April 2015 and is currently scaling up ITN distribution via antenatal care visits and other channels. As many studies have demonstrated, ITN use increases significantly following ITN distribution programs [22,[53][54][55][56][57][58][59][60][61][62][63][64]. Future evaluations will hopefully confirm this for Liberia. ...
Article
Full-text available
Malaria is a major cause of morbidity and mortality in Liberia. At the same time, insecticide-treated net (ITN) ownership and use remain low. Access is a key determinant of ITN use but it is not the only one; prior studies have identified factors that affect the use of ITNs in households with at least one ITN. These factors operate at the individual, household, and community levels. However, studies have generally not assessed the psychosocial or ideational determinants of ITN use. Using 2014 household survey data, this manuscript examines the socio-demographic, ideational, household, and community factors associated with household member use of ITNs in Liberia. Multilevel modeling was used to assess fixed effects at the individual, household, and community levels, and random effects at the household and cluster levels. The data showed significant residual clustering at the household level, indicating that there were unmeasured factors operating at this level that are associated with ITN use. The association of age with ITN use was moderated by sex such that men, older children, and teenagers were less likely to sleep under an ITN compared to women and children under five years old. Female caregivers' perceived severity of malaria, perceived self-efficacy to detect a complicated case of malaria, and exposure to the "Take Cover" communication campaign were positively associated with ITN use by members of her household. The association with household size was negative, while the relationship with the number of ITNs was positive. Programs should seek to achieve universal coverage (that is, one ITN for every two household members) and promote the notion that everyone needs to sleep under an ITN every night. Programs should also seek to strengthen perceived severity of malaria and educate intended audience groups on the signs of malaria complications. Given the significance of residual clustering at the household level, interventions that engage men as heads of household and key decision-makers are relevant.
... However, merely owning a net or being able to access one does not automatically translate into its use, as previous studies have often reported [10][11][12]. Indeed, the 2014 Uganda malaria indicator survey (MIS) showed that 79 % of the household population had access to an LLIN (measured by the proportion of the population that could sleep under an LLIN if each LLIN in the household were used by up to two people) within their household and yet 69 % of these households slept under it [13]. ...
Article
Full-text available
Background Uganda conducted an LLIN mass distribution campaign in 2013 with the goal of achieving universal coverage. Using data from the 2014 malaria indicator survey, this analysis estimated the proportion of the population with access to an LLIN that slept under one the night before the survey and factors associated with not using an LLIN in households that had achieved universal coverage. Methods This was a secondary data analysis using the 2014 malaria indicator survey dataset. The outcome was use of an LLIN among households that achieved universal coverage, while independent variables include age, gender, number of household members, residence, number of sleeping rooms, spraying of rooms with insecticide, number of children under 5 years of age, number of women of child-bearing age, relationship structure and community distribution of ant-malarial medicine. Results Overall, 3361 (62 %) households of the 5345 achieved universal coverage and were included in the analysis giving a total population of 14,450 individuals. Of these, 11,884 (80.10 %) reported to have slept under an LLIN the night before the survey. Children between 6 and 14 years were significantly less likely to use an LLIN when compared to those under 5 years (75.26 vs 83.12 %), [adjusted OR, 1.29 (1.11–1.49), p = 0.001]. The odds of not using an LLIN, significantly increased from households with five members when compared to those that had one member (79.53 vs 84.88 %), [adjusted OR, 2.16 (1.38–3.38), p = 0.001] and rising even further in households with six or more members (78.04 vs 84.88 %), [OR, 2.27 (1.36–3.71), p = 0.003]. Conclusions This analysis has showed that 80 % of the population used an LLIN among households that achieved universal coverage following the 2013 mass distribution campaign, especially among children under 5 years, an operational success in this category. However, children between 6 and 14 years and individuals from households with five or more numbers are less likely to use the LLINs. In order to improve usage in these categories, it may require re-focusing the behaviour change communication message to be all-inclusive, especially in era of universal coverage, and to increase the number of LLINs distributed in households with more than four members during future mass distribution campaigns, respectively.
... African countries with co-distribution experience include the following: Togo – ITNs with measles and polio immunization and mebendazole in 2004 (Wolkon, et al., November 2010); Niger – LLINs and polio vaccination in 2005 and 2006 (Thwing, et al., June 2008); Senegal -ITN vouchers with mebendazole and vitamin A in 2009 (Thwing, et al., April 2011). ...
... Although mass distribution campaigns have proven to be the best approach to rapidly increase ITN coverage [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19], the best strategy for implementing them is still under debate. Various strategies have been used to deliver, allocate, and distribute ITNs to households. ...
Article
Full-text available
Background The use of insecticide-treated nets (ITNs) is widely recognized as one of the main interventions to prevent malaria. High ITN coverage is needed to reduce transmission. Mass distribution campaigns are the fastest way to rapidly scale up ITN coverage. However, the best strategy to distribute ITNs to ensure household coverage targets are met is still under debate. This paper presents results from 14 post-campaign surveys in five African countries to assess whether the campaign strategy used had any effect on distribution outcome. Methods Data from 13,901 households and 14 campaigns from Ghana, Nigeria, Senegal, South Sudan and Uganda, were obtained through representative cross-sectional questionnaire surveys, conducted three to 16 months after ITN distribution. All evaluations used a multi-stage sampling approach and similar methods for data collection. Key outcomes examined were the proportion of households having received a net from the campaign and the proportion of households with one net for every two people. Results Household registration rates proved to be the most important determinant of a household receiving any net from the campaign (adjusted odds ratio [OR] 74.8; 95 % confidence interval [CI]: 55.3–101.1) or had enough ITNs for all household members (adjusted OR 19.1; 95 % CI: 55.34–101.05). Factors that positively influenced registration were larger household size (adjusted OR 1.7; 95 % CI: 1.5–2.1) and families with children under five (adjusted OR 1.4; 95 % CI: 1.2–1.6). Urban residence was negatively associated with receipt of a net from the campaign (adjusted OR 0.73; 95 % CI: 0.58–0.92). Registration was equitable in most campaigns except for Uganda and South Sudan, where the poorest wealth quintiles were less likely to have been reached. After adjusting for other factors, delivery strategy (house-to-house vs. fixed point) and distribution approach (integrated versus stand-alone) did not show a systematic impact on registration or owning any ITN. Campaigns that used a universal coverage allocation strategy were more effective in increasing the proportion of households with enough ITNs than campaigns that used a fixed number of ITNs. Registering based on counting usual sleeping spaces resulted in higher levels of households with one net per two people among those receiving any campaign net (adjusted OR 1.6; 95 % CI: 1.07–2.48) than campaigns that registered based on the number of household members. Conclusion All of the campaigns, irrespective of strategy, successfully increased ownership of at least one ITN. Delivery method and distribution approach were not associated with receipt of at least one ITN from the campaign. Rather, the key determining factor for receipt of at least one ITN from the campaign was a successful registration process, which depends on the ability of community volunteers to reach households during the exercise. Universal coverage campaigns, especially those that used a sleeping space allocation strategy, were more effective in increasing the proportion of households with enough ITNs. Maximizing registration completeness and using a universal coverage allocation strategy are therefore likely to improve campaign outcomes.
Experiment Findings
Full-text available
Factors Affecting Utilisation of Insecticide Treated Net among Household with Children Less than Five Years
Article
Full-text available
Abstract Malaria is hyper-endemic in Somalia and remains one of the leading causes of morbidity and mortality, especially vulnerable groups such as old people, pregnant women, and children under five years. The prevalence of the disease is the highest along the rivers, settlements in southern Somalia, with artificial water reservoirs, where there is a year-round transmission. About 80% of malaria cases in Somalia occur in the Shebelle and Juba river basins. Outside of the malaria-endemic areas, it is estimated that 87% of Somalia is at risk of being exposed to malaria epidemics. According to a recent KAP (knowledge, attitude, and practices) survey, less than 10% of the households have Insecticide-treated mosquito net. This cross-sectional study was conducted to describe the factors affecting utilization of Insecticide-treated net among households with children under 5 years in Hodan district. The study was all adult households (more than 18 yrs.) with five years. A total of 50 respondents were interviewed during the period of data collection. A structured questionnaire dealing with socio-demographic characteristics, household’s knowledge about the Insecticide-treated net and availability and ownership and uses of Insecticide-treated net were used as data collection instrument. Results were presented in frequency tables and graphics. The majority of respondents indicated that 30 out of 50 (60%) have Insecticide-treated mosquito net while 20 out of 50 (40%) do not have it. The main reason for those who do not have Insecticide-treated mosquito net they did not able to afford it. Knowledge about malaria and Insecticide-treated mosquito net importance, the majority of respondents (92%) believe that there is a great benefit to use Insecticide-treated mosquito net for a reason to protect them mosquito bites.20 (40%) were primary education and they didn’t know the causes of malaria (38 out of 50, 76%). The households of the Hodan district need special attention to the utilization of Insecticide-treated mosquito net. Free provision of Insecticide-treated net awareness creation on the utilization of Insecticide-treated mosquito nets and participated in an income generates supremely important activities. This study demonstrated a wide gap between knowledge, Insecticide-treated mosquito net ownership, and Utilization among the household with children less than 5 years. Therefore, the suggested recommendations arising from this study are for effective case management and control efforts of malaria. One of the strongest weapons in the fight against malaria is the use of insecticide-treated mosquito net while sleeping. Keywords Malaria, Insecticide Treated Bed Nets, Household, A Mosquito Net
Article
Full-text available
Abstract- Over 3 billion people across the world are at risk of malaria infection every year. This burden is compounded by the fact that approximately 2-3 million children live with human immunodeficiency virus (HIV) in sub-Saharan Africa. Malaria and HIV account for a significant amount of morbidity and mortality with an estimated 22.5 million people living with HIV. While Cotrimoxazole prevents opportunistic infections in HIV-infected persons, its effectiveness in preventing malaria varies especially in children. This study determined the correlates and incidence of P. falciparum infection among HIV positive and negative children < 5 years in Kisumu County. Data analysis was done using Stata version 14 statistical. Cumulative incidence of 17.42% was realised over three months follow up. Being a non-parametric test of difference between two groups of non-parametric data, Man-Whitney U test was conducted to assess the difference between malaria incidence in HIV POSITIVE and HIV negative. There was significant difference in incidence of P. falciparum among HIV infected compared to HIV non-infected children (p-value = 0.0030). symptoms presented; Fever RR 0.69 (95%CI: 0.22-2.16), headache RR 1.53 (95%CI: 0.12-19.08).Inability to retain oral medication RR 0.12: (95%C: 0.01-1.92), number of persons per bednet use where two, RR 5.46 (95%CI: 0.46-64.58), three 2.14 (95%CI: 0.27-17.25) and > three 2.58 (95%CI: 0.27-24.87) were associated with the risk of malaria. Index Terms- Correlates, Cotrimoxazole, HIV, cumulative Incidence, P. falciparum.
Article
Full-text available
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.
Article
Full-text available
Background Continuous distribution of insecticide-treated nets (ITNs) has now been accepted as one way of sustaining ITN universal coverage. Community-based channels offer an interesting means of delivering ITNs to households to sustain universal ITN coverage. The objective of this study was to provide proof of concept for this channel. Methods A 9-month, community-based, distribution pilot was implemented beginning 1 year after a mass campaign in Lainya County, South Sudan from 2012 to 2013. Following social mobilization, community members could request an ITN from a net coupon holder. Eligibility criteria included having lost an ITN, giving birth outside of the health facility, or not having enough ITNs for all household members. After verification, households could exchange the coupon for an ITN at a distribution point. The evaluation was a pre/post design using representative household surveys with two-stage cluster sampling and a sample size of 600 households per survey. Results At endline, 78% of respondents were aware of the scheme and 89% of those also received an ITN through community-based distribution. Population access to ITNs nearly doubled, from 38% at baseline to 66% after the pilot. Household ownership of any ITN and enough ITNs (1 for 2 people) also increased significantly, from 66 to 82% and 19 to 46%, respectively. Community-based distribution was the only source of ITNs for 53.4% of households. The proportion of the population using an ITN last night increased from 22.7% at baseline to 53.9% at endline. A logistic regression model indicates that although behaviour change communication was positively associated with an increase in ITN use, access to enough nets was the greatest determinant of use. Conclusions ITN access and use improved significantly in the study area during the pilot, coming close to universal coverage targets. This pilot serves as proof of concept for the community-based distribution methodology implemented as a mechanism to sustain ITN universal coverage. Longer periods of implementation should be evaluated to determine whether community-based distribution can successfully maintain ITN coverage beyond the short term, and reach all wealth quintiles equitably. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-2020-8) contains supplementary material, which is available to authorized users.
Article
Purpose This paper aims to introduce key concepts from practice theory (PT) to the social change agenda and draw on the unique contributions of the social marketing field. PT has underpinned a growing stream of research in pro-environmental studies seeking to reduce impacts of particular behaviours, but it remains theoretical. By drawing on social marketing’s applied roots, this paper introduces a practice-theoretical intervention planning process (P-TIPP) which frames the unique contribution of social marketing in behaviour change and foregrounds practice- not individual-level change. Design/methodology/approach The P-TIPP draws on the total process planning model, introducing the concept of “practice as entity” and “practice as performance” to frame intervention planning tasks. The process locates the contribution of social marketing within a transdisciplinary framework which emphasises transforming collective conventions. Findings This is a conceptual paper, but the possibility for PT to make a significant contribution to the world of social marketing is outlined. Research limitations/implications P-TIPP is untested. Also, practices can be difficult to identify and somewhat abstract. Finally, it can be challenging to introduce the approach to policy, funding and practitioner procedures. Practical implications The implications of P-TIPP are that social change interventions are devised, underpinned and planned using insights from PT, such as the way behavioural patterns fit into broader understandings of practice. The subsequent social change agenda will be inherently transdisciplinary, sustainable and reduce focus on individual power to change. Originality/value This paper is a first attempt at exploring what PT, and social marketing can learn from each other for the future effectiveness of social change activity.
Data
Full-text available
Published studies used to estimate empirical prior for net discard rate. (0.01 MB PDF)
Article
Full-text available
Information on the impact of insecticide (permethrin)-treated bed nets (ITNs) from randomized controlled trials in areas of intense perennial malaria transmission is limited. As part of a large-scale, community-based, group-randomized controlled trial of the effect of ITNs on childhood mortality in a holoendemic area in western Kenya, we conducted three cross-sectional surveys in 60 villages to assess the impact of ITNs on morbidity in 1,890 children less than three years old. Children in ITN and control villages were comparable pre-intervention, but after the introduction of ITNs, children in intervention villages were less likely to have recently experienced illness requiring treatment (protective efficacy [95% confidence intervals] = 15% [1-26%]), have an enlarged spleen (32% [20-43%]), be parasitemic (19% [11-27%]), have clinical malaria (44% [6-66%]), have moderately severe anemia (hemoglobin level < 7.0 g/dL; 39% [18-54%]), or have a pruritic body rash, presumably from reduced nuisance insect bites (38% [24-50%]). Use of ITNs was also associated with significantly higher mean weight-for-age Z-scores and mid-upper arm circumferences. There was no evidence, however, that ITNs reduced the risk of helminth infections, diarrhea, or upper or lower respiratory tract infections. The ITNs substantially reduced malaria-associated morbidity and improved weight gain in young children in this area of intense perennial malaria transmission.
Article
Full-text available
Spatial analyses of the effect of insecticide (permethrin)-treated bed nets (ITNs) on nearby households both with and without ITNs was performed in the context of a large-scale, group-randomized, controlled mortality trial in Asembo, western Kenya. Results illustrate a protective effect of ITNs on compounds lacking ITNs located within 300 meters of compounds with ITNs for child mortality, moderate anemia, high-density parasitemia, and hemoglobin levels. This community effect on nearby compounds without nets is approximately as strong as the effect observed within villages with ITNs. This implies that in areas with intense malaria transmission with high ITN coverage, the primary effect of insecticide-treated nets is via area-wide effects on the mosquito population and not, as commonly supposed, by simple imposition of a physical barrier protecting individuals from biting. The strength of the community effect depended upon the proportion of nearby compounds with treated nets. To maximize their public health impact, high coverage with treated nets is essential.
Article
Full-text available
Information on the impact of insecticide (permethrin)-treated bed nets (ITNs) from randomized controlled trials in areas of intense perennial malaria transmission is limited. As part of a large-scale, community-based, group-randomized controlled trial of the effect of ITNs on childhood mortality in a holoendemic area in western Kenya, we conducted three cross-sectional surveys in 60 villages to assess the impact of ITNs on morbidity in 1,890 children less than three years old. Children in ITN and control villages were comparable pre-intervention, but after the introduction of ITNs, children in intervention villages were less likely to have recently experienced illness requiring treatment (protective efficacy [95% confidence intervals] = 15% [1-26%]), have an enlarged spleen (32% [20-43%]), be parasitemic (19% [11-27%]), have clinical malaria (44% [6-66%]), have moderately severe anemia (hemoglobin level < 7.0 g/dL; 39% [18-54%]), or have a pruritic body rash, presumably from reduced nuisance insect bites (38% [24-50%]). Use of ITNs was also associated with significantly higher mean weight-for-age Z-scores and mid-upper arm circumferences. There was no evidence, however, that ITNs reduced the risk of helminth infections, diarrhea, or upper or lower respiratory tract infections. The ITNs substantially reduced malaria-associated morbidity and improved weight gain in young children in this area of intense perennial malaria transmission.
Article
Full-text available
The impact of insecticide (permethrin)-treated bed nets (ITNs) on malaria in pregnancy was studied in a rural area in western Kenya with intense perennial malaria transmission. All households in 40 of 79 villages were randomized to receive ITNs by January 1997. The ITNs were distributed in control villages two years later. Complete data on birth outcome were available on 2,754 (89.6%) of 3,072 deliveries. Women (n = 780) were followed monthly throughout pregnancy in 19 of 79 villages. Among gravidae 1-4, ITNs were associated with reductions of 38% (95% confidence interval [CI] = 17-54%) in the incidence of malaria parasitemia and 47% (95% CI = 6-71%) in the incidence of severe malarial anemia (hemoglobin level < 8 g/dL with parasitemia) during pregnancy. At the time of delivery, mean hemoglobin levels were 0.6 g/dL (95% CI = 0.01-1.2 g/dL) higher, the prevalence of placental or maternal malaria was reduced by 35% (95% CI = 20-47%), and the prevalence of low birth weight was reduced by 28% (95% CI = 2-47%) in gravidae 1-4 from ITN villages. No beneficial impact was observed in gravidae five or higher. In areas of intense perennial malaria transmission, permethrin-treated bed nets reduce the adverse effect of malaria during the first four pregnancies.
Article
Full-text available
We assessed the proportion of febrile children less than five years old with prompt effective antimalarial treatment and the proportion of those less than five years old sleeping under insecticide-treated nets (ITNs) or any mosquito net the preceding night in African malarious countries. Data were reviewed from 23 Multiple Indicator Cluster Surveys and 13 Demographic and Health Surveys conducted between 1998 and 2002. A median of 53% of febrile children received antimalarial treatment. A median of 84% of these treatments, however, involved chloroquine, and the proportion of treatments given within two days of onset of symptoms was unknown in most surveys. Median coverages of those less than five years old with any net and ITNs were 15% and 2%, respectively. Use of nets, and especially ITNs, was consistently lower in rural than in urban areas. At the outset of intensified malaria control under Roll Back Malaria, coverage with principal interventions was far below the target of 60% set for Africa in 2005.
Article
Full-text available
We present results from a study conducted in western Kenya where all-cause child mortality was assessed among a population with high levels of sustained insecticide-treated bed net (ITN) use for up to six years. Although ITNs were associated with significant reductions in all-cause mortality among infants 1-11 months old, there was no difference in the rate of all-cause mortality among children 12-59 months old with ITNs for 2-4 years, compared historically with children from villages without ITNs, after controlling for seasonality and underlying child mortality across calendar years (adjusted hazard ratio [AHR] = 0.91, 95% confidence interval [CI] = 0.77-1.07). There was no increase in the proportion of child deaths at older ages (12-59 months old) of all child deaths within villages with ITNs for 5-6 years (48.1%) compared historically with villages without ITNs (47.9%), after controlling for seasonality (AHR = 1.03, P = 0.834). We find no evidence that sustained ITN use increased the risk of mortality in older children in this area of intense perennial malaria transmission.
Article
Full-text available
Population coverage of insecticide-treated nets (ITNs) in Africa falls well below the Abuja target of 60% while coverage levels achieved during vaccination campaigns in the same populations typically exceed 90%. Household (HH) cost of ITNs is an important barrier to their uptake. We investigated the coverage, equity and cost of linking distribution of free ITNs to a measles vaccination campaign. During a national measles vaccination campaign in Zambia, children in four rural districts were given a free ITN when they received their measles vaccination. In one urban district, children were given a voucher, which could be redeemed for a net at a commercial distribution site. About 1700 HHs were asked whether they received vaccination and an ITN during a measles campaign, as well as questions on assets (e.g. type roofing material or bicycle ownership) to assess HH wealth. Net ownership was calculated for children in each wealth quintile. In the rural areas, ITN coverage among children rose from 16.7% to 81.1% and the equity ratio from 0.32 to 0.88 and in the urban area from 50.7% to 76.2% (equity ratio: 0.66-1.19). The operational cost per ITN delivered was dollar 0.35 in the rural area with direct distribution and $1.89 in the urban areas with voucher distribution. Mass distribution of ITNs through vaccination campaigns achieves rapid, high and equitable coverage at low cost.
Article
Full-text available
The development of mosquito nets pre-treated with insecticide, Long Lasting Impregnated Nets (LLINs) that last the life span of the net, is a solution to the difficulty of the re-impregnation of conventional nets. Even if they showed a good efficacy in control conditions, their efficacy in the field, particularly in areas with resistance of Anopheles gambiae to pyrethroids, is not well documented. This study compares wide (Olyset) and small (Permanet) mesh LLINs in field conditions, using entomological parameters. The two LLINs were tested in a rice-growing area of south-western Burkina Faso (West Africa) with year around high density of the main malaria vector An. gambiae s.s. In the study village (VK6), there is a mixed population of two molecular forms of An. gambiae, the S-form which dominates during the rainy season and the M-form which dominates the rest of the year. The two LLINs Olyset and Permanet were distributed in the village and 20 matched houses were selected for comparison with four houses without treated nets. Mosquito entrance rate was ten fold higher in control houses than in houses with LLINs and there was no difference between the two net types. Among mosquitoes found in the houses, 36 % were dead in LLIN houses compared to 0% in control houses. Blood feeding rate was 80 % in control houses compared to 43 % in LLIN houses. The type of net did not significantly impact any of these parameters. No mosquitoes were found inside Permanet, whereas dead or dying mosquitoes were collected inside the Olyset. More than 60% of mosquitoes found on top or inside the nets had had blood meals from cattle, as shown by ELISA analysis. The percentage of blood-fed mosquitoes in a bed net study does not necessarily determine net success. The efficacy of the two types of LLINs was comparable, during a period when the S-form of An. gambiae was carrying the kdr gene. Significantly higher numbers of mosquitoes were collected in control houses compared to intervention houses, indicating that the LLINs provided an additional deterrent effect, which enhanced their expected prevention capacity.
Article
Full-text available
As efforts are currently underway to roll-out insecticide-treated bednets (ITNs) to populations within malarious areas in Africa, there is an unprecedented need for data to measure the effectiveness of such programmes in terms of population coverage. This paper examines methodological issues to using household surveys to measure core Roll Back Malaria coverage indicators of ITN possession and use. ITN coverage estimates within Anseba and Gash Barka Provinces from the 2002 Eritrean Demographic and Health Survey, implemented just prior to a large-scale ITN distribution programme, are compared to estimates from the same area from a sub-national Bednet Survey implemented 18 months later in 2003 after the roll-out of the ITN programme. Measures of bednet possession were dramatically higher in 2003 compared to 2002. In 2003, 82.2% (95% confidence interval (CI) 77.4-87.0) of households in Anseba and Gash Barka possessed at least one ITN. RBM coverage indicators for ITN use were also dramatically higher in 2003 as compared to 2002, with 76.1% (95% CI 69.9-82.2) of children under five years old and 52.4% (95% CI 38.2-66.6) of pregnant women sleeping under ITNs. The ITN distribution programme resulted in a gross increase in ITN use among children and pregnant women of 68.3% and 48% respectively. Eritrea has exceeded the Abuja targets of 60% coverage for ITN household possession and use among children under five years old within two malarious provinces. Results point to several important potential sources of bias that must be considered when interpreting data for ITN coverage over time, including: disparate survey universes and target populations that may include non-malarious areas; poor date recall of bednet procurement and treatment; and differences in timing of surveys with respect to malaria season.
Article
Full-text available
There is much emphasis on social marketing as a means of scaling up coverage with insecticide-treated nets and the question has arisen whether nets provided free-of-charge will be looked after by householders. Over several years questionnaires and surveys of usage and condition of nets were carried out throughout a town and 15 villages in north-east Tanzania, where nets and insecticide have to be purchased and in 24 other villages where over 15000 nets had been donated and annual re-treatment is provided free-of-charge. There was very high population coverage in the town but, in the villages where nets have to be purchased, only 9.3% of people used nets which were intact and/or had been insecticide-treated and could, therefore, provide protection. However, where nets had been provided free, over 90% of the nets were still present and were brought for re-treatment several years later. In this part of Tanzania, social marketing has performed well in a town but very poorly in villages. However, the study showed that people look after and bring for re-treatment nets which had been provided free-of-charge.
Article
Full-text available
Malaria prevention in Africa merits particular attention as the world strives toward a better life for the poorest. Insecticide-treated nets (ITNs) represent a practical means to prevent malaria in Africa, so scaling up coverage to at least 80% of young children and pregnant women by 2010 is integral to the Millennium Development Goals (MDG). Targeting individual protection to vulnerable groups is an accepted priority, but community-level impacts of broader population coverage are largely ignored even though they may be just as important. We therefore estimated coverage thresholds for entire populations at which individual- and community-level protection are equivalent, representing rational targets for ITN coverage beyond vulnerable groups. Using field-parameterized malaria transmission models, we show that high (80% use) but exclusively targeted coverage of young children and pregnant women (representing <20% of the population) will deliver limited protection and equity for these vulnerable groups. In contrast, relatively modest coverage (35%-65% use, with this threshold depending on ecological scenario and net quality) of all adults and children, rather than just vulnerable groups, can achieve equitable community-wide benefits equivalent to or greater than personal protection. Coverage of entire populations will be required to accomplish large reductions of the malaria burden in Africa. While coverage of vulnerable groups should still be prioritized, the equitable and communal benefits of wide-scale ITN use by older children and adults should be explicitly promoted and evaluated by national malaria control programmes. ITN use by the majority of entire populations could protect all children in such communities, even those not actually covered by achieving existing personal protection targets of the MDG, Roll Back Malaria Partnership, or the US President's Malaria Initiative.
Article
Full-text available
We introduce an innovative method that uses personal digital assistants (PDAs) equipped with global positioning system (GPS) units in household surveys to select a probability-based sample and perform PDA-based interviews. Our approach uses PDAs with GPS to rapidly map all households in selected areas, choose a random sample, and navigate back to the sampled households to conduct an interview. We present recent field experience in two large-scale nationally representative household surveys to assess insecticide-treated bed net coverage as part of malaria control efforts in Africa. The successful application of this method resulted in statistically valid samples; quality-controlled data entry; and rapid aggregation, analyses, and availability of preliminary results within days of completing the field work. We propose this method as an alternative to the Expanded Program on Immunization cluster sample method when a fast, statistically valid survey is required in an environment with little census information at the enumeration area level.
Article
Full-text available
Inexpensive and efficacious interventions that avert childhood deaths in sub-Saharan Africa have failed to reach effective coverage, especially among the poorest rural sectors. One particular example is insecticide-treated bed nets (ITNs). In this study, we present repeat observations of ITN coverage among rural Kenyan homesteads exposed at different times to a range of delivery models, and assess changes in coverage across socioeconomic groups. We undertook a study of annual changes in ITN coverage among a cohort of 3,700 children aged 0-4 y in four districts of Kenya (Bondo, Greater Kisii, Kwale, and Makueni) annually between 2004 and 2006. Cross-sectional surveys of ITN coverage were undertaken coincidentally with the incremental availability of commercial sector nets (2004), the introduction of heavily subsidized nets through clinics (2005), and the introduction of free mass distributed ITNs (2006). The changing prevalence of ITN coverage was examined with special reference to the degree of equity in each delivery approach. ITN coverage was only 7.1% in 2004 when the predominant source of nets was the commercial retail sector. By the end of 2005, following the expansion of heavily subsidized clinic distribution system, ITN coverage rose to 23.5%. In 2006 a large-scale mass distribution of ITNs was mounted providing nets free of charge to children, resulting in a dramatic increase in ITN coverage to 67.3%. With each subsequent survey socioeconomic inequity in net coverage sequentially decreased: 2004 (most poor [2.9%] versus least poor [15.6%]; concentration index 0.281); 2005 (most poor [17.5%] versus least poor [37.9%]; concentration index 0.131), and 2006 with near-perfect equality (most poor [66.3%] versus least poor [66.6%]; concentration index 0.000). The free mass distribution method achieved highest coverage among the poorest children, the highly subsidised clinic nets programme was marginally in favour of the least poor, and the commercial social marketing favoured the least poor. Rapid scaling up of ITN coverage among Africa's poorest rural children can be achieved through mass distribution campaigns. These efforts must form an important adjunct to regular, routine access to ITNs through clinics, and each complimentary approach should aim to make this intervention free to clients to ensure equitable access among those least able to afford even the cost of a heavily subsidized net.
Article
Previously published as an Appendix to the World development report. Incl. users guide, list of acronyms, bibl., index. The Little data book is a pocket edition of WDI
Article
Malaria is an important cause of illness and death in many parts of the world, especially in Africa. There has been a renewed emphasis on preventive measures, both at community and at individual level. Insecticide treated bednets and curtains are a promising preventive measure. The objective of this review was to assess the effects of insecticide-treated bednets or curtains in preventing malaria We searched the Cochrane Infectious Diseases Group trials register, Medline, Embase and the reference lists of articles. We handsearched journals, contacted researchers, funding agencies and net and insecticide manufacturers. Randomized and quasi-randomized trials of insecticide-treated bednets or curtains with a sufficient dose of a suitable insecticide compared with nets without insecticide or no nets at all. Studies including pregnant women were excluded. Trial quality was assessed and data extracted by the reviewer. Trial inclusions/exclusions were reviewed by two independent individuals. Of 65 identified studies, 18 were included. Of these, 11 were randomized by cluster rather than individually. Mortality in children under five was measured in four trials. When impregnated nets were compared with plain nets or no nets, the summary relative risk was 0. 83. This translates to an estimate of protective efficacy of 17%. For treated nets compared with untreated nets, the relative risk of child mortality was 0.77. About six lives can be saved each year for every 1000 children protected with insecticide-treated nets. Insecticide-treated nets also reduced the incidence of mild malarial episodes by 48% (controls=no nets) and 34% (controls=untreated nets). Insecticide-treated nets appear to be effective in reducing childhood mortality and morbidity from malaria. Widespread access to insecticide-treated nets will require major financial, technical and operational inputs.
Article
Insecticide-treated nets have proven efficacy as a malaria-control tool in Africa. However, the transition from efficacy to effectiveness cannot be taken for granted. We assessed coverage and the effect on child survival of a large-scale social marketing programme for insecticide-treated nets in two rural districts of southern Tanzania with high perennial malaria transmission. Socially marketed insecticide-treated nets were introduced step-wise over a 2-year period from May, 1997, in a population of 480000 people. Cross-sectional coverage surveys were done at baseline and after 1, 2, and 3 years. A demographic surveillance system (DSS) was set up in an area of 60000 people to record population, births, and deaths. Within the DSS area, the effect of insecticide-treated nets on child survival was assessed by a case-control approach. Cases were deaths in children aged between 1 month and 4 years. Four controls for each case were chosen from the DSS database. Use of insecticide-treated nets and potential confounding factors were assessed by questionnaire. Individual effectiveness estimates from the case-control study were combined with coverage to estimate community effectiveness. Insecticide-treated net coverage of infants in the DSS area rose from less than 10% at baseline to more than 50% 3 years later. Insecticide-treated nets were associated with a 27% increase in survival in children aged 1 month to 4 years (95% CI 3-45). Coverage in such children was higher in areas with longer access to the programme. The modest average coverage achieved by 1999 in the two districts (18% in children younger than 5 years) suggests that insecticide-treated nets prevented 1 in 20 child deaths at that time. Social marketing of insecticide-treated nets has great potential for effective malaria control in rural African settings.
Article
Kenya's National Malaria Strategy states that insecticide-treated nets (ITNs) would be considered as a free service to pregnant women assuming sufficient financial commitment from donors. In 2001, United Nation's Children's Fund (UNICEF) and the Government of Kenya brokered support to procure and distribute nets and K-O TABs (deltamethrin) to 70 000 pregnant women in 35 districts throughout Kenya around Africa Malaria Day. This intervention represented the single largest operational distribution of ITN services in Kenya to date, and this study evaluates its success, limitations and costs. The tracking process from the central level through to antenatal clinic (ANC) facilities suggests that of the 70 000 nets procured, 37 206 nets (53%) had been distributed to pregnant women throughout the country within 12 weeks. One-fifth of the nets procured (14 117) had gone out to individuals other than pregnant women, most of these at the request of the district teams, with only 2870 nets estimated to have gone astray at the ANC facilities. At 12 weeks, the remaining 18 677 nets were still in storage awaiting distribution, with more than two-thirds having reached the district, and nearly half already being held at ANC facilities. The cost of getting a net and K-O TAB to an ANC facility ready for distribution to a pregnant woman was US$ 3.81. Accounting for the 14 117 nets that had gone to other users, the cost for an ITN received by a pregnant woman was US$ 5.26. Delivering ITNs free to pregnant women through ANCs uses an existing system (with positive spin-offs of low delivery cost and simple logistics), is equitable (as it not only targets those who can afford it) and can have the added benefits of strengthening ANC service, delivery and use.
Article
To investigate the strengths and weaknesses of the indicators 'proportion of households possessing mosquito net(s)' and 'proportion of children under 5 years of age who slept under a net the preceding night' for monitoring malaria control. Review of data from household surveys including demographic and health surveys in sub-Saharan African countries. Net possession ranged among 14 surveyed regions from 0.1% to 28.5% for insecticide-treated nets (ITNs) and among 69 regions from 3.6% to 79.7% for any net. Reported use during the preceding night by children under 5 years of age was between 0% and 16% for ITNs and between 0.7% and 74.5% for any net. On average, in households owning ITN(s), 55% of children slept under it (R2 = 0.97, P < 0.001). For any net, use was -4.2% + 0.875 x possession (R2 = 0.89, P < 0.001); the use of nets, however, also varied somewhat among the surveyed countries (P = 0.003). In-depth surveys suggested that use was lower than possession because: (i). nets were scarce (mean 1.8 per possessing household); (ii). nets were not always used for children and (iii). use was lower during hot, dry months than during cool rainy months, and many surveys had been conducted in the dry season. Not all mosquito nets owned by African households are being used for young children. Household education on the consistent use of nets for this vulnerable group is called for in malaria control programmes. Regular, district-level rapid assessments of household possession of nets should complement ongoing in-depth surveys. Data on 'use during the preceding night' must be interpreted taking the survey season into account.
Article
Malaria is an important cause of illness and death in many parts of the world, especially in sub-Saharan Africa. There has been a renewed emphasis on preventive measures at community and individual levels. Insecticide-treated nets (ITNs) are the most prominent malaria preventive measure for large-scale deployment in highly endemic areas. To assess the impact of insecticide-treated bed nets or curtains on mortality, malarial illness (life-threatening and mild), malaria parasitaemia, anaemia, and spleen rates. I searched the Cochrane Infectious Diseases Group trials register (January 2003), CENTRAL (The Cochrane Library, Issue 1, 2003), MEDLINE (1966 to October 2003), EMBASE (1974 to November 2002), LILACS (1982 to January 2003), and reference lists of reviews, books, and trials. I handsearched journals, contacted researchers, funding agencies, and net and insecticide manufacturers. Individual and cluster randomized controlled trials of insecticide-treated bed nets or curtains compared to nets without insecticide or no nets. Trials including only pregnant women were excluded. The reviewer and two independent assessors reviewed trials for inclusion. The reviewer assessed trial methodological quality and extracted and analysed data. Fourteen cluster randomized and eight individually randomized controlled trials met the inclusion criteria. Five trials measured child mortality: ITNs provided 17% protective efficacy (PE) compared to no nets (relative rate 0.83, 95% confidence interval (CI) 0.76 to 0.90), and 23% PE compared to untreated nets (relative rate 0.77, 95% CI 0.63 to 0.95). About 5.5 lives (95% CI 3.39 to 7.67) can be saved each year for every 1000 children protected with ITNs. In areas with stable malaria, ITNs reduced the incidence of uncomplicated malarial episodes in areas of stable malaria by 50% compared to no nets, and 39% compared to untreated nets; and in areas of unstable malaria: by 62% for compared to no nets and 43% compared to untreated nets for Plasmodium falciparum episodes, and by 52% compared to no nets and 11% compared to untreated nets for P. vivax episodes. When compared to no nets and in areas of stable malaria, ITNs also had an impact on severe malaria (45% PE, 95% CI 20 to 63), parasite prevalence (13% PE), high parasitaemia (29% PE), splenomegaly (30% PE), and their use improved the average haemoglobin level in children by 1.7% packed cell volume. ITNs are highly effective in reducing childhood mortality and morbidity from malaria. Widespread access to ITNs is currently being advocated by Roll Back Malaria, but universal deployment will require major financial, technical, and operational inputs.
Article
Treated mosquito nets are a practical malaria control tool. However, implementation of efficient delivery mechanisms remains a challenge. We investigated whether social marketing of treated mosquito nets results in decreased equity in rural Tanzania, through household surveys before the start of a social marketing programme and 3 years later. About 12,000 household heads were asked about ownership of nets and other assets including a tin roof, radio, or bicycle. A socio-economic status score was developed for each household. Net ownership was calculated for households in each quintile of this score, from poorest to least poor. In 1997, about 20% of the poorest households and over 60% of the least poor households owned a mosquito net. Three years later, more than half of the poorest households owned a net, as did over 90% of the least poor: the ratio of net ownership among the poorest to least poor increased from 0.3 in 1997 to 0.6 in 2000. Social marketing in the presence of an active private sector for nets was associated with increased equity.
Article
Widespread coverage of vulnerable populations with insecticide-treated nets (ITNs) constitutes an important component of the Roll Back Malaria (RBM) strategy to control malaria. The Abuja Targets call for 60% coverage of children under 5 years of age and pregnant women by 2005; but current coverage in Africa is unacceptably low. The RBM 'Strategic Framework for Coordinated National Action in Scaling-up Insecticide-Treated Netting Programmes in Africa' promotes coordinated national action and advocates sustained public provision of targeted subsidies to maximise public health benefits, alongside support and stimulation of the private sector. Several countries have already planned or initiated targeted subsidy schemes either on a pilot scale or on a national scale, and have valuable experience which can inform future interventions. The WHO RBM 'Workshop on mapping models for delivering ITNs through targeted subsidies' held in Zambia in 2003 provided an opportunity to share and document these country experiences. This paper brings together experiences presented at the workshop with other information on experiences of targeting subsidies on ITNs, net treatment kits and retreatment services (ITN products) in order to describe alternative approaches, highlight their similarities and differences, outline lessons learnt, and identify gaps in knowledge. We find that while there is a growing body of knowledge on different approaches to targeting ITN subsidies, there are significant gaps in knowledge in crucial areas. Key questions regarding how best to target, how much it will cost and what outcomes (levels of coverage) to expect remain unanswered. High quality, well-funded monitoring and evaluation of alternative approaches to targeting ITN subsidies is vital to develop a knowledge base so that countries can design and implement effective strategies to target ITN subsidies.
Article
Background: Mass, free distribution (Catch-up) of insecticide-treated bednets (ITNs) during measles vaccination campaigns achieves immediate, high and equitable coverage for both ITNs and measles vaccine. Maintaining high coverage over time requires long-term, routine access to new nets (Keep-up). In many settings, only one approach--either campaign or routine delivery--has been available and have been seen as competing methods. Relying only on campaigns achieves high coverage at the cost of lack of later access. Relying solely on routine coverage builds a delivery infrastructure but may lead to slower rates of coverage and inequities. A combined Catch-up/Keep-up approach has been a common feature of vaccination programs for many years. We assessed the 3-year effects of a one-time Catch-up campaign followed by clinic-based social marketing for routine Keep-up on ITN coverage and use. Methods: In December 2002, ITNs were distributed to all children attending a measles vaccination campaign in a rural district of Ghana. In the 3 years following that campaign, the district began offering ITNs at a subsidized price to pregnant women attending ante-natal clinics. This Keep-up scheme did not become fully operational until 2 years after the campaign. A coverage survey was conducted 38-month post-campaign using a standard two-stage cluster sampling method. Results: Coverage of nets was high due to the combined contributions of both Catch-up and Keep-up. There were 475 households in the survey with at least one child less than 5 years of age. Among these households, coverage was 95.6% with any net, 83.8% with a campaign net, and 73.9% with an ITN. Of all children, 95.7% slept in a household that had a net, 86.1% slept in a household that had a campaign net. Not all available nets were used as only 59.6% of children slept under an ITN. The source of the nets was 77.7% from the campaign and 20% from routine clinics. Compared to households that participated in the campaign, households with children born after the campaign had higher rates of net ownership (75.1% vs. 67.7%, P=0.04). Equity was high as the ratio of coverage in the lowest wealth quintile to that in the highest was 0.95 for ITN ownership and 1.08 for ITN use. These coverage and use rates were similar to those previously reported 5-month post-campaign, suggesting no decrease over 3 years. Conclusion: A high level of ITN coverage and use was achieved and sustained by sequential community-based mass campaign Catch-up and clinic-based Keep-up distribution. The campaign nets covered virtually all extant households while clinic-based distribution provided nets for the new sleeping spaces created post-campaign. Because nets can be shared, and most children are born into families that already have a net, the number of new nets needed to sustain high coverage is substantially lower than the number of newborn children. A Catch-up/Keep-up strategy combining mass campaigns for children and clinic-based distribution to pregnant women is an efficient strategy for achieving and sustaining high net coverage. Assuring proper use of nets is a remaining challenge.
Final report: National education campaign of mothers in the utilisation of mosquito nets or ''Hang-Up'' International Federation of the Red Cross Community-wide Effects of Permethrin-treated Bed Nets on Child Mortality and Malaria Morbidity in Western Kenya
  • Haskew
  • Geneva
  • Switzerland
  • Wa Hawley
  • Ter Phillips-Howard Pe
  • Kuile
  • Fo
Haskew J (2006) Final report: National education campaign of mothers in the utilisation of mosquito nets or ''Hang-Up'' International Federation of the Red Cross, Geneva, Switzerland. Hawley WA, Phillips-Howard PE, Ter Kuile FO et al. (2003) Community-wide Effects of Permethrin-treated Bed Nets on Child Mortality and Malaria Morbidity in Western Kenya. American Journal of Tropical Medicine and Hygiene 68(Suppl. 4), 121–127.
Personal protection of long lasting insecticide-treated nets in areas of Anopheles gambiae s.s. resistance to pyrethroids Effect of sustained insecticide-treated bed net use on all-cause child mortality in an area of intense perennial transmission in western Kenya