Article

Mosquito nets and the poor: Can social marketing redress inequities in access?

Authors:
  • Tanzania Commision for Science and Technology
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Abstract

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.

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... Measures of SES are therefore increasingly incorporated into studies. Given the importance of insecticide treated nets (ITNs) as a public health intervention, estimating inequalities in access to ITNs and how these change over time has been an important aspect of monitoring progress towards the Abuja declaration and the Millennium Development Goals (Nathan et al. 2004;Onwujekwe et al. 2004;Uzochukwu and Onwujekwe 2004;Grabowsky et al. 2005;Wiseman et al. 2005;Noor et al. 2006Noor et al. , 2007. Findings from these studies have fed into recommendations on how to improve levels of ITN coverage and use among disadvantaged populations. ...
... Various approaches to measuring SES exist, including 'direct' measures such as income, expenditure and consumption, and 'proxy' measures mainly in the form of asset indices (Falkingham and Namazie 2002). While income and consumption are considered the traditional gold standard measures of SES, asset indices are increasingly being applied in the health and development literature (Filmer and Pritchett 2001;Montgomery et al. 2000;Nathan et al. 2004;Noor et al. 2006Noor et al. , 2007Onwujekwe et al. 2004;Uzochukwu and Onwujekwe 2004). Despite the wide application of asset indices, few studies have shown: the sensitivity of findings to the choice of SES measure; whether the nature of disparities for bednet ownership differs depending on the welfare measure selected; and how the results might differ when rural and urban data are analysed separately or as a combined sample. ...
... Approaches to construct asset indices have included: summing whether or not a household possesses certain assets (Montgomery et al. 2000); weighting each asset by its market value (Conteh et al. 2000); factor analysis, which allows the use of a few components to explain the correlation structure between assets (Sahn and Stifel 2001); principal component analysis (PCA) that uses statistical techniques to determine the asset weights used in the index; and the Polychoric PCA, which uses maximum likelihood to capture the quality of assets, by treating assets like ordinal variables, rather than creating binary variables for each category (Kolenikov and Angeles 2004). Of these, the PCA has been one of the most widely applied (Filmer and Pritchett 2001;McKenzie 2003;Schellenberg et al. 2003;Nathan et al. 2004;Onwujekwe et al. 2004;Grabowsky et al. 2005;Noor et al. 2006Noor et al. , 2007. Briefly, PCA seeks to describe the variation of a set of multivariate data in terms of a set of uncorrelated linear combinations of variables. ...
Article
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Research on the impact of socio-economic status (SES) on access to health care services and on health status is important for allocating resources and designing pro-poor policies. Socio-economic differences are increasingly assessed using asset indices as proxy measures for SES. For example, several studies use asset indices to estimate inequities in ownership and use of insecticide treated nets as a way of monitoring progress towards meeting the Abuja targets. The validity of different SES measures has only been tested in a limited number of settings, however, and there is little information on how choice of welfare measure influences study findings, conclusions and policy recommendations. In this paper, we demonstrate that household SES classification can depend on the SES measure selected. Using data from a household survey in coastal Kenya (n = 285 rural and 467 urban households), we first classify households into SES quintiles using both expenditure and asset data. Household SES classification is found to differ when separate rural and urban asset indices, or a combined asset index, are used. We then use data on bednet ownership to compare inequalities in ownership within each setting by the SES measure selected. Results show a weak correlation between asset index and monthly expenditure in both settings: wider inequalities in bednet ownership are observed in the rural sample when expenditure is used as the SES measure [Concentration Index (CI) = 0.1024 expenditure quintiles; 0.005 asset quintiles]; the opposite is observed in the urban sample (CI = 0.0518 expenditure quintiles; 0.126 asset quintiles). We conclude that the choice of SES measure does matter. Given the practical advantages of asset approaches, we recommend continued refinement of these approaches. In the meantime, careful selection of SES measure is required for every study, depending on the health policy issue of interest, the research context and, inevitably, pragmatic considerations.
... Important steps have been taken particularly to scaleup the implementation of LLINs/LLINs in Ethiopia. In 2006/2007, about 16 million LLINs were distributed to about 8 million households in malarious areas of the country [5,6]. To date, about 20 million LLINs/ LLINs have been distributed through Regional Health Bureaus and other stakeholders. ...
... On the other hand half of the bed nets in the community were tucked under the mattress, and other places where other insects were. In rural Ethiopia where the hygiene problem is prevalent, this problem is given special emphasis than mosquitoes particularly in non malaria transmission season [6,7]. ...
Article
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Introduction: Malaria is the leading cause of morbidity and mortality in Afar Region. Distribution of Long Lasting Insecticide Treated Bed Nets (LLINs) has been one of the major interventions to combat malaria. However, ownership and utilization of these nets are not well known. Methods: A community based cross-sectional study was conducted using interviewer-administered questionnaires to study LLIN coverage. After systematic random sampling of the study population, data on utilization of LLINs and factors influencing this utilization were collected. Analysis of these data was done using SPSS software. Results: Household possession of at least one LLIN in the surveyed households was found in 648(86.1%) households. Ownership of at least two nets was found among 419(55.6%) surveyed households. The proportion of children under 5 years of age who slept under treated nets during the night preceding the survey was 728(82.0%) and 676 (76.1%) in the surveyed households for reported and observed respectively. Likewise, the proportion of pregnant women who slept under treated nets was 166 (79.1%) and 147(70.0%) for reported and observed respectively. Among the potential determinants explored regarding utilization of LLINs, age, occupation, and radio possession were found to be significantly associated with LLIN utilization. Households that did not possess radio were 0.38 times (95%CI= 0.25-0.59) less likely to let their children under five and pregnant women sleep under LLIN. Conclusion: The LLINs coverage and utilization among the pastoralist community are promising. Strengthening of the primary health care unit and timely replacement of LLINs are critical for improved outcomes.
... Important steps have been taken particularly to scaleup the implementation of LLINs/LLINs in Ethiopia. In 2006/2007, about 16 million LLINs were distributed to about 8 million households in malarious areas of the country [5,6]. To date, about 20 million LLINs/ LLINs have been distributed through Regional Health Bureaus and other stakeholders. ...
... On the other hand half of the bed nets in the community were tucked under the mattress, and other places where other insects were. In rural Ethiopia where the hygiene problem is prevalent, this problem is given special emphasis than mosquitoes particularly in non malaria transmission season [6,7]. ...
Article
Full-text available
Malaria is the leading cause of morbidity and mortality in Afar Region. Distribution of Long Lasting Insecticide Treated Bed Nets (LLINs) has been one of the major interventions to combat malaria. However, ownership and utilization of these nets are not well known. A community based cross-sectional study was conducted using interviewer-administered questionnaires to study LLIN coverage. After systematic random sampling of the study population, data on utilization of LLINs and factors influencing this utilization were collected. Analysis of these data was done using SPSS software. Household possession of at least one LLIN in the surveyed households was found in 648(86.1%) households. Ownership of at least two nets was found among 419(55.6%) surveyed households. The proportion of children under 5 years of age who slept under treated nets during the night preceding the survey was 728(82.0%) and 676 (76.1%) in the surveyed households for reported and observed respectively. Likewise, the proportion of pregnant women who slept under treated nets was 166 (79.1%) and 147(70.0%) for reported and observed respectively. Among the potential determinants explored regarding utilization of LLINs, age, occupation, and radio possession were found to be significantly associated with LLIN utilization. Households that did not possess radio were 0.38 times (95%CI= 0.25-0.59) less likely to let their children under five and pregnant women sleep under LLIN. The LLINs coverage and utilization among the pastoralist community are promising. Strengthening of the primary health care unit and timely replacement of LLINs are critical for improved outcomes.
... We found some evidence of disparities in vaccination coverage by socio-economic status, with ratios of coverage in the poorest to least poor of 0.8 to 0.9, as reported else- where [28]. We also found stark inequalities in the use of mosquito nets, parasitaemia and anaemia, similar to those found before a social marketing program for nets in another part of the country [29] . Inequalities in underweight were also in keeping with a previous survey in another part of rural Tanzania (J Schellenberg unpublished data). ...
... Inequalities in underweight were also in keeping with a previous survey in another part of rural Tanzania (J Schellenberg unpublished data). However, we were surprised to find no evidence of socio-economic disparities in either care-seeking for mild illness, admission to hospital, or infant survival, in contrast to findings both nationally [28] and locally [6,293031. This seems unlikely to be due to a lack of power as we had over 100 child deaths in each quintile. ...
Article
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With a view to developing health systems strategies to improve reach to high-risk groups, we present information on health and survival from household and health facility perspectives in five districts of southern Tanzania. We documented availability of health workers, vaccines, drugs, supplies and services essential for child health through a survey of all health facilities in the area. We did a representative cluster sample survey of 21,600 households using a modular questionnaire including household assets, birth histories, and antenatal care in currently pregnant women. In a subsample of households we asked about health of all children under two years, including breastfeeding, mosquito net use, vaccination, vitamin A, and care-seeking for recent illness, and measured haemoglobin and malaria parasitaemia. In the health facility survey, a prescriber or nurse was present on the day of the survey in about 40% of 114 dispensaries. Less than half of health facilities had all seven 'essential oral treatments', and water was available in only 22%. In the household survey, antenatal attendance (88%) and DPT-HepB3 vaccine coverage in children (81%) were high. Neonatal and infant mortality were 43.2 and 76.4 per 1000 live births respectively. Infant mortality was 40% higher for teenage mothers than older women (RR 1.4, 95% confidence interval (CI) 1.1 - 1.7), and 20% higher for mothers with no formal education than those who had been to school (RR 1.2, CI 1.0 - 1.4). The benefits of education on survival were apparently restricted to post-neonatal infants. There was no evidence of inequality in infant mortality by socio-economic status. Vaccine coverage, net use, anaemia and parasitaemia were inequitable: the least poor had a consistent advantage over children from the poorest families. Infant mortality was higher in families living over 5 km from their nearest health facility compared to those living closer (RR 1.25, CI 1.0 - 1.5): 75% of households live within this distance. Relatively short distances to health facilities, high antenatal and vaccine coverage show that peripheral health facilities have huge potential to make a difference to health and survival at household level in rural Tanzania, even with current human resources.
... In a previous study conducted in rural areas, knowledge, attitude and behavior practices regarding malaria were shown to influence the ITN ownership . Different studies have also confirmed a socioeconomically stratified gradient of treated and untreated net ownership and re-treatment rates (Hanson & Worall, 2002;Nathan et al., 2004). In order for large-scale ITN distribution programme to succeed, the knowledge gaps, practices and attitudes that may negatively influence the intervention uptake, need to be identified and addressed. ...
... In other studies, low bed net ownership has been attributed to low affordability and inaccessibility of the community (Nathan et al., 2004;Magesa et al., 2005). Consequently, affordability of mosquito nets has been shown to be a major factor limiting wide and equitable coverage of mosquito nets, particularly in rural settings characterized by the poorer segments of the population (reviewed by Magesa et al., 2005). ...
Article
Full-text available
Community knowledge and practice related to malaria is important for the implementation of appropriate, effective and sustainable interventions. This study was carried out to assess knowledge and practices on malaria and identify factors contributing to the low mosquito net coverage in Simanjiro District in northern Tanzania. A combination of direct observation, focus group discussion (FGD) and questionnaire were employed in data collection. A sample of 200 respondents was selected randomly from 5542 people from the study village. The findings show that, although most (75%) of the respondents were informed that mosquitoes transmit malaria, the remaining quarter of respondents reserved a considerable doubt on the link between mosquitoes and malaria. Sixty five percent of the respondents were aware of the use of insecticide treated nets (ITNs). However, the coverage of any mosquito net and ITN was 12.5% and 5%, respectively. Affordability, unavailability and gender inequality were identified to be major factors associated with the low ITN coverage. The study recommends that, an advocated pluralistic approach of ITN delivery which encourages a coordinated public private alliance is required to ensure equitable and large scale distribution of ITNs in the village.
... The availability of soap in the household, for example, declines with increased distance to the water tap, 77 and insecticide treated bednets are less likely to be available in poor households. 78 Maternal factors are also likely to contribute to inequalities in childhood mortality. Inequalities in modern contraceptive use are large and increasing. ...
... 103 A social marketing campaign in Tanzania reduced relative inequalities in ownership of insecticide treated bednets. 78 Differential consequences of ill-health can be diminished by reducing out-of-pocket expenditures for health care through, for example, universal health insurance and other pre-payment mechanisms. 61 Addressing inequalities within the health care sector is important. ...
Article
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In low- and middle-income countries (LMICs), the probability of dying in childhood is strongly related to the socio-economic position of the parents or household in which the child is born. This article reviews the evidence on the magnitude of socio-economic inequalities in childhood mortality within LMICs, discusses possible causes and highlights entry points for intervention. Sources of data Evidence on socio-economic inequalities in childhood mortality in LMICs is mostly based on data from household surveys and demographic surveillance sites. Childhood mortality is systematically and considerably higher among lower socio-economic groups within countries. Also most proximate mortality determinants, including malnutrition, exposure to infections, maternal characteristics and health care use show worse levels among more deprived groups. The magnitude of inequality varies between countries and over time, suggesting its amenability to intervention. Reducing inequalities in childhood mortality would substantially contribute to improving population health and reaching the Millennium Development Goals (MDGs). The contribution of specific determinants, including national policies, to childhood mortality inequalities remains uncertain. What works to reduce these inequalities, in particular whether policies should be universal or targeted to the poor, is much debated. The increasing political attention for addressing health inequalities needs to be accompanied by more evidence on the contribution of specific determinants, and on ways to ensure that interventions reach lower socio-economic groups.
... In addition, the commercial sector is hitherto the main source of nets and the promoters of social marketing believe a strong competitive market leads to higher quality , lower prices and wider availability for all. Data from several studies indicate that post-intervention inequalities in net use are lower following free distribution during measles vaccination campaigns or stand-alone campaigns than following social marketing interventions2728293043,454647 . For example in Kilombero and Ulanga districts , Tanzania, prior to a social marketing programme only 20% of the poorest households owned a net compared to 60% for the least poor, improving to about 50% and 90% respectively three years post implementation [43,46] . ...
... Data from several studies indicate that post-intervention inequalities in net use are lower following free distribution during measles vaccination campaigns or stand-alone campaigns than following social marketing interventions2728293043,454647 . For example in Kilombero and Ulanga districts , Tanzania, prior to a social marketing programme only 20% of the poorest households owned a net compared to 60% for the least poor, improving to about 50% and 90% respectively three years post implementation [43,46] . However, after mass distribution alongside a measles campaign in Zambia and Ghana the difference in utilisation between the lowest and highest quintiles was much closer (78% compared to 88% in Zambia, and 62% compared to 75% in Ghana) [27,28] and in Ghana the difference was not statistically significant. ...
Article
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Studies show that the burden of malaria remains huge particularly in low-income settings. Although effective malaria control measures such as insecticide-treated nets (ITNs) have been promoted, relatively little is known about their equity dimension. Understanding variations in their use in low-income settings is important for scaling up malaria control programmes particularly ITNs. The objective of this paper is to measure the extent and causes of inequalities in the ownership and utilisation of bed nets across socioeconomic groups (SEGs) and age groups in Tanga District, north-eastern Tanzania. A questionnaire was administered to heads of 1,603 households from rural and urban areas. Households were categorized into SEGs using both an asset-based wealth index and education level of the household head. Concentration indices and regression-based measures of inequality were computed to analyse both vertical and horizontal inequalities in ownership and utilisation of bed nets. Focus Group Discussions (FGDs) were used to explore community perspectives on the causes of inequalities. Use of ITNs remained appallingly low compared to the RBM target of 80% coverage. Inequalities in ownership of ITNs and all nets combined were significantly pro-rich and were much more pronounced in rural areas. FGDs revealed that lack of money was the key factor for not using ITNs followed by negative perceptions about the effect of insecticides on the health of users. Household SES, living within the urban areas and being under-five were positively associated with bed net ownership and/or utilisation. The results highlight the need for mass distribution of ITN; a community-wide programme to treat all untreated nets and to promote the use of Long-Lasting Insecticidal nets (LLINs) or longer-lasting treatment of nets. The rural population and under-fives should be targeted through highly subsidized schemes and mass distribution of free nets. Public campaigns are also needed to encourage people to use treated nets and mitigate negative perceptions about insecticides.
... The difference is due to lack of access to buy the bed net and lack of affordability as confirmed in the FGD discussion. This evidence is supported by a study done in southern Tanzania [19]. Regarding utilization of the total respondents who owned at least one LLINs 68.6 % of them used it in the previous night of data collection. ...
Article
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Introduction: Communities’ malaria prevention and control methods practices contribute immensely to sustainable control of malaria. This evidence is quite limited in the study area. Hence, this study aimed to assess Malaria prevention and control methods practice and associated factors among rural households. Method: Community-based cross-sectional mixed quantitative and qualitative study was conducted from April to June 2020, in the West Belessa district. We considered a 740 sample size. We used structured and semi-structured questionnaires for quantitative and qualitative components respectively. We collected the data by interviewing for quantitative and focus group discussion for qualitative. The data was coded and entered using Epi info7 and analyzed using SPSS software. We fitted the binary logistic regression model to identify the associated factors. Result: A total of 738 subjects were included with a 99.7% response rate. Half, 50.9% of respondents had a good malaria prevention and control methods practice. Long-lasting insecticide nets (LLINs) and insecticide residual spray (IRS) were practiced by 21.1% and 80.5% respectively. Poorest, poor, medium and rich wealth quintiles with [AOR=0.45, 95% CI: 0.27, 0.76], [AOR=0.51, 95% CI:0.30, 0.88], [AOR=0.24, 95% CI: 0.14, 0.42] and [AOR=0.21, 95% CI: 0.12, 0.36] respectively Gond ebrareg Kebele [AOR=3.88, 95% CI: 2.43,6.20], female [AOR=0.65, 95% CI: 0.47, 0.90], illiterate [AOR=0.34, 95% CI 0.16, 0.72], poor knowledge [AOR=0.52, 95% CI: 0.36, 0.75] were significantly associated with good malaria prevention practice. All of the FGD participants. Conclusion: IRS and environmental management malaria prevention and control methods practices were relatively high. However, LLINs and other malaria prevention methods were poorly practiced. Wealth index, respondents living kebele, female sex, educational status, and respondents’ malaria prevention knowledge are positively associated with the practice of malaria prevention.
... This evidence is supported by a study done in southern Tanzania. (19) Regarding utilization of the total respondents who owned at least one LLINs 68.6 % of them used it in the previous night of data collection this is in line with a study done in Gurage and a study done in Dabat district Amhara region. (10,20) The FMOH's National Malaria Strategic Plan aims to provide 100% IRS coverage as a key malaria prevention measure in areas where the malaria burden is high. ...
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Background: In Ethiopia, the burden of malaria continues to cause a substantial number of morbidity and mortality. Communities’ practices of malaria prevention and control methods contribute immensely to sustainable control of malaria. This evidence is quite limited in the study area. Hence, this study aimed to assess Practice of malaria prevention and control methods and associated factors among rural household in west belessa district, northwest Ethiopia, 2019. Method: Community-based cross-sectional mixed quantitative and qualitative study was conducted from April to June 2019, in West Belessa district, North West Ethiopia. Multistage sampling was used to select a 740 sample size. A structured questionnaire was used for the quantitative component and a semi-structured questionnaire for the qualitative component. Quantitative data collected by interviewing and qualitative data using focus group discussion. Quantitative data was coded and entered using Epi info software and analyzed using SPSS. The binary logistic regression model was fitted to identify the associated factors. Odds Ratio with 95% Confidence Interval was used to assess the strength of association. The qualitative data was transcribed manually using the thematic approach. Result: A total 738 subjects included with 99.7% response rate. 50.9% of respondents had good practice of malaria prevention and control methods. LLINs and IRS were practiced by 21.1% and 80.5% respectively. Poorest wealth quintiles [AOR = 0.45, 95% CI: 0.27, 0.76], poor wealth quintiles [AOR=0.51, 95% CI: 0.30, 0.88], medium wealth quintiles [AOR = 0.24, 95% CI: 0.14, 0.42] and wealthy wealth quintile [AOR = 0.21, 95% CI: 0.12, 0.36], living in Menti Kebele [AOR = 3.88, 95% CI: 2.43,6.20], female sex [AOR = 0.65, 95% CI: 0.47, 0.90], illiterate educational status [AOR = 0.34, 95% CI 0.16, 0.72] knowledge level poor [AOR = 0.52, 95% CI: 0.36, 0.75] were significantly associated with good malaria prevention practice. All of the FGD participants participated at least one malaria prevention method. Conclusion: There were good IRS and environmental management malaria prevention practices, however, LLINs and other malaria prevention methods were poorly practiced. Wealth index, respondents living kebele, female sex, educational status, and respondents’ malaria prevention knowledge are predictors for the practice of malaria prevention.
... By 2004 great progress was being made as health authorities revitalized efforts towards equity, and novel delivery methods such as social marketing and mass distribution became popular [57][58][59][60][61][62]. In Malawi, there was 8% coverage with any net in 2000 but this had quickly risen to 36% with ITNs by 2004 [63]. ...
Article
Full-text available
Background: Bed nets are the commonest malaria prevention tool and arguably the most cost-effective. Their efficacy is because they prevent mosquito bites (a function of physical durability and integrity), and kill mosquitoes (a function of chemical content and mosquito susceptibility). This essay follows the story of bed nets, insecticides and malaria control, and asks whether the nets must always have insecticides. Methods: Key attributes of untreated or pyrethroid-treated nets are examined alongside observations of their entomological and epidemiological impacts. Arguments for and against adding insecticides to nets are analysed in contexts of pyrethroid resistance, personal-versus-communal protection, outdoor-biting, need for local production and global health policies. Findings: Widespread resistance in African malaria vectors has greatly weakened the historical mass mosquitocidal effects of insecticide-treated nets (ITNs), which previously contributed communal benefits to users and non-users. Yet ITNs still achieve substantial epidemiological impact, suggesting that physical integrity, consistent use and population-level coverage are increasingly more important than mosquitocidal properties. Pyrethroid-treatment remains desirable where vectors are sufficiently susceptible, but is no longer universally necessary and should be re-examined alongside other attributes, e.g. durability, coverage, acceptability and access. New ITNs with multiple actives or synergists could provide temporary relief in some settings, but their performance, higher costs, and drawn-out innovation timelines do not justify singular emphasis on insecticides. Similarly, sub-lethal insecticides may remain marginally-impactful by reducing survival of older mosquitoes and disrupting parasite development inside the mosquitoes, but such effects vanish under strong resistance. Conclusions: The public health value of nets is increasingly driven by bite prevention, and decreasingly by lethality to mosquitoes. For context-appropriate solutions, it is necessary to acknowledge and evaluate the potential and cost-effectiveness of durable untreated nets across different settings. Though ~ 90% of malaria burden occurs in Africa, most World Health Organization-prequalified nets are manufactured outside Africa, since many local manufacturers lack capacity to produce the recommended insecticidal nets at competitive scale and pricing. By relaxing conditions for insecticides on nets, it is conceivable that non-insecticidal but durable, and possibly bio-degradable nets, could be readily manufactured locally. This essay aims not to discredit ITNs, but to illustrate how singular focus on insecticides can hinder innovation and sustainability.
... Additional strategies exist, such as socially promoted and subsidized nets for sale at markets; and hang-up keep-up strategies, to tackle the problem of new nets being saved for the future instead of as replacement of the current nets. [32][33][34][35] Cambodian national malaria policy calls for distribution of LLINs to all people living in malaria-endemic regions. The program aims to ensure that the known barriers to the effective scaling-up of insecticidal nets are adequately addressed: 1) LLINS are distributed locally and free of charge, so there are no financial barriers; 2) LLINS are distributed one per one person per village unit, so every single household member should have access to an LLIN; and 3) distribution rounds occur once every 2 years, assuring continued access to effective LLINs. ...
Article
Distributing long-lasting insecticidal nets (LLINs) to individuals living in malaria-endemic regions is a cornerstone of global malaria control. National malaria control programs aim to achieve "universal coverage" of at-risk populations to reach LLINs' full potential to reduce malaria, progress of which is then measured by indicators constructed from standardized questionnaires. Through an exploration of variability in LLIN use in Cambodia, we argue that indicators of universal coverage of LLINs are not sufficiently commensurate with the realities they are intended to measure, limiting the suitability of the data to serve program and policy purposes in a malaria elimination era. Reflecting on the various sources of variability in LLIN use, we apply and extend the concept of "appropriateness" as a third prong to the widely used "efficacy" and "effectiveness" criteria for evaluating LLINs as a tool for malaria prevention. Describing first the different dimensions of the intervention and the sociocultural context separately, we will further show how the variability underlying both is affected and induced by inappropriate aspects of the intervention and the measurements of its impact. We consider the gap between "net use" and the numerical representations of such local net use justifies further exploration of potential strategies to improve LLIN use in subgroups where persisting malaria transmission clusters.
... However, the effectiveness of these strategies varies [123]. Social marketing was not able to achieve equity consistently and reach those most at-risk populations in selected projects involving ITNs [147,148] and anti-malarials through the AMFm in some study sites [149,150]. ...
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Background In malaria elimination settings, all malaria cases must be identified, documented and investigated. To facilitate complete and timely reporting of all malaria cases and effective case management and follow-up, engagement with private providers is essential, particularly in settings where the private sector is a major source of healthcare. However, research on the role and performance of the private sector in malaria diagnosis, case management and reporting in malaria elimination settings is limited. Moreover, the most effective strategies for private sector engagement in malaria elimination settings remain unclear. Methods Twenty-five experts in malaria elimination, disease surveillance and private sector engagement were purposively sampled and interviewed. An extensive review of grey and peer-reviewed literature on private sector testing, treatment, and reporting for malaria was performed. Additional in-depth literature review was conducted for six case studies on eliminating and neighbouring countries in Southeast Asia and Southern Africa. Results The private health sector can be categorized based on their commercial orientation or business model (for-profit versus nonprofit) and their regulation status within a country (formal vs informal). A number of potentially effective strategies exist for engaging the private sector. Conducting a baseline assessment of the private sector is critical to understanding its composition, size, geographical distribution and quality of services provided. Facilitating reporting, referral and training linkages between the public and private sectors and making malaria a notifiable disease are important strategies to improve private sector involvement in malaria surveillance. Financial incentives for uptake of rapid diagnostic tests and artemisinin-based combination therapy should be combined with training and community awareness campaigns for improving uptake. Private sector providers can also be organized and better engaged through social franchising, effective regulation, professional organizations and government outreach. Conclusion This review highlights the importance of engaging private sector stakeholders early and often in the development of malaria elimination strategies. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-1901-1) contains supplementary material, which is available to authorized users.
... 16 936 studies were then eliminated based on the above inclusion criteria. Full-text review further removed another 440 studies, yielding 125 eligible studies for inclusion in analysis (Figure 2, see also supplementary material) (Alisjahbana et al. 1995; Schopper et al. 1995; Pinfold and Horan 1996; Agha 1998;, 2003 De Pee et al. 1998; Valente and Saba 1998; Ford and Koetsawang 1999; Pinfold 1999; Schellenberg et al. 1999 Schellenberg et al. , 2001 Laukamm-Josten et al. 2000; Meekers 2000; Meekers 2000, 2007; Vaughn et al. 2000; Abdulla et al. 2001; Agha et al. 2001 Agha et al. , 2006 Agha et al. , 2007a Babalola et al. 2001a, b; Curtis et al. 2001; Dunston et al. 2001; Karlyn 2001; Jaramillo 2001; Kim et al. 2001 Kim et al. , 2006 Boulay et al. 2002; Rowland et al. 2002 Rowland et al. , 2004 Thevos et al. 2002; Collumbien and Douthwaite 2003; Jacobs et al. 2003; Tambashe et al. 2003; Zagré et al. 2003; Basu et al. 2004; Nathan et al. 2004; ShefnerRogers and Sood 2004; Warnick et al. 2004; Crape et al. 2005; Goldstein et al. 2005; Kanal et al. 2005; Khan et al. 2005; Kikumbih et al. 2005; Mathanga et al. 2005; Meekers et al. 2005; Paulino et al. 2005; Baker et al. 2006; Garc ıa et al. 2006; Hammett et al. 2006 Hammett et al. , 2012 Hutchinson et al. 2006; Keating et al. 2006; Shargie et al. 2006; Sweat et al. 2006; Decker and Montagu 2007; Hoke et al. 2007; Lö nnroth et al. 2007; Noor et al. 2007; Plautz and Meekers 2007; Ross et al. 2007; Sun et al. 2007; Thuong et al. 2007; Wu et al. 2007; Garrett et al. 2008; Mü ller et al. 2008; O'Reilly et al. 2008; Rimal and Creel 2008; Yeung et al. 2008; Hanson et al. 2009; Hounton et al. 2009; Wang et al. 2009 Wang et al. , 2011 Agha and Meekers 2010; Alba et al. 2010; Blanton et al. 2010; Baizhumanova et al. 2010; Casey et al. 2010 Casey et al. , 2013 Gutierrez et al. 2010; Lutalo et al. 2010; Ngo et al. 2010; Piot et al. 2010; Qureshi 2010; Sheth et al. 2010; Angeles-Agdeppa et al. 2011; Bahromov 2011; Doyle et al. 2011; Elder et al. 2011; Hamby et al. 2011; Kassegne et al. 2011; Longfield et al. 2011; Mainkar et al. 2011; Nambiar et al. 2011; Pandey et al. 2011; Rachakulla et al. 2011; Shah et al. 2011; Thilakavathi et al. 2011; Agha and Beaudoin 2012; Garc ıa et al. 2012; Harris et al. 2012; Hotz et al. 2012; Huntington et al. 2012; Patel et al. 2012; Russo et al. 2012; Azmat et al. 2013; Boily et al. 2013; Bowen 2013; Habib et al. 2013; Havemann et al. 2013; Jain et al. 2013; Juneja et al. 2013; Kang et al. 2013; Littrell et al. 2013; Loharikar et al. 2013; Monterrosa et al. 2013; Obare et al. 2013; Pawa et al. 2013; Pattanayak et al. 2009; Gupta et al. 2012). Fifteen studies contained results that were analysed for multiple health areas. ...
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Social marketing is a commonly used strategy in global health. Social marketing programmes may sell subsidized products through commercial sector outlets, distribute appropriately priced products, deliver health services through social franchises and promote behaviours not dependent upon a product or service. We aimed to review evidence of the effectiveness of social marketing in low- and middle-income countries, focusing on major areas of investment in global health: HIV, reproductive health, child survival, malaria and tuberculosis. We searched PubMed, PsycInfo and ProQuest, using search terms linking social marketing and health outcomes for studies published from 1995 to 2013. Eligible studies used experimental or quasi-experimental designs to measure outcomes of behavioural factors, health behaviours and/or health outcomes in each health area. Studies were analysed by effect estimates and for application of social marketing benchmark criteria. After reviewing 18 974 records, 125 studies met inclusion criteria. Across health areas, 81 studies reported on changes in behavioural factors, 97 studies reported on changes in behaviour and 42 studies reported on health outcomes. The greatest number of studies focused on HIV outcomes (n = 45) and took place in sub-Saharan Africa (n = 67). Most studies used quasi-experimental designs and reported mixed results. Child survival had proportionately the greatest number of studies using experimental designs, reporting health outcomes, and reporting positive, statistically significant results. Most programmes used a range of methods to promote behaviour change. Programmes with positive, statistically significant findings were more likely to apply audience insights and cost-benefit analyses to motivate behaviour change. Key evidence gaps were found in voluntary medical male circumcision and childhood pneumonia. Social marketing can influence health behaviours and health outcomes in global health; however evaluations assessing health outcomes remain comparatively limited. Global health investments are needed to (i) fill evidence gaps, (ii) strengthen evaluation rigour and (iii) expand effective social marketing approaches.
... From a continuous distribution in Tanzania, the frequently mentioned KINET social marketing project, Nathan et al. (98) reported an increase in equity ratio for any net ownership over a period of three years from 0.3 to 0.6. A similarly high equity ratio of 0.68 was also reported from Nigeria based on a consumer survey in 2000 when no campaign distributions had yet taken place and the commercial sector was the primary source of nets (64). ...
... Cost and distribution are the major barriers to protect target groups or communities and social marketing can effectively reduce the inequity to access the ITNs (Nathan et al., 2004). ...
... ).DSS can be used to quantify equity in health in the area (ArmstrongINDEPTH Network 2005;Nathan et al. 2004) and also assist in assessing poverty monitoring strategies. DSS complements other information systems such as the Demographic and Health Surveys and Tanzania, like many countries in Sub Saharan Africa is faced with the dearth of reliable information for planning due to fragmentary routine data collection systems. ...
... 10 This was achieved because the programme dramatically increased net ownership and improved equity of ownership. 11 In other studies related to the KINET project, we showed that treated nets had a protective efficacy of 62% and 63% for parasitaemia and anaemia, respectively, among children under 2 years of age. 12 Among pregnant women, protective efficacy was 23% for parasitaemia and 38% for severe anaemia, respectively. ...
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The Ifakara Rural HDSS (125 000 people) was set up in 1996 for a trial of the effectiveness of social marketing of bed nets on morbidity and mortality of children aged under 5 years, whereas the Ifakara Urban HDSS (45 000 people) since 2007 has provided demographic indicators for a typical small urban centre setting. Jointly they form the Ifakara HDSS (IHDSS), located in the Kilombero valley in south-east Tanzania. Socio-demographic data are collected twice a year. Current malaria work focuses on phase IV studies for antimalarials and on determinants of fine-scale variation of pathogen transmission risk, to inform malaria elimination strategies. The IHDSS is also used to describe the epidemiology and health system aspects of maternal, neonatal and child health and for intervention trials at individual and health systems levels. More recently, IHDSS researchers have studied epidemiology, health-seeking and national programme effectiveness for chronic health problems of adults and older people, including for HIV, tuberculosis and non-communicable diseases. A focus on understanding vulnerability and designing methods to enhance equity in access to services are cross-cutting themes in our work. Unrestricted access to core IHDSS data is in preparation, through INDEPTH iSHARE [www.indepth-ishare.org] and the IHI data portal [http://data.ihi.or.tz/index.php/catalog/central]. © The Author 2015; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association.
... Effective CHW case management has been linked to the level of training, transport means, adequate supervision, access to medicines and educational tools, and sufficient incentives [7][8][9][10][11]. Barriers, however, can reduce effectiveness of CHW service delivery, including inadequate training, supervision, and remuneration, as well as insufficient assimilation of CHWs into the health system [12,13]. ...
Article
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Community health workers (CHWs) can play important roles in primary health care delivery, particularly in settings of health workforce shortages. However, little is known about CHWs' perceptions of barriers and motivations, as well as those of the beneficiaries of CHWs. In Rwanda, which faces a significant gap in human resources for health, the Ministry of Health expanded its community health programme beginning in 2007, eventually placing 4 trained CHWs in every village in the country by 2009. The aim of this study was to assess the capacity of CHWs and the factors affecting the efficiency and effectiveness of the CHW programme, as perceived by the CHWs and their beneficiaries. As part of a larger report assessing CHWs in Rwanda, a cross-sectional descriptive study was conducted using focus group discussions (FGDs) to collect qualitative information regarding educational background, knowledge and practices of CHWs, and the benefits of community-based care as perceived by CHWs and household beneficiaries. A random sample of 108 CHWs and 36 beneficiaries was selected in 3 districts according to their food security level (low, middle and high). Qualitative and demographic data were analyzed. CHWs were found to be closely involved in the community, and widely respected by the beneficiaries. Rwanda's community performance-based financing (cPBF) was an important incentive, but CHWs were also strongly motivated by community respect. The key challenges identified were an overwhelming workload, irregular trainings, and lack of sufficient supervision. This study highlights the challenges and areas in need of improvement as perceived by CHWs and beneficiaries, in regards to a nationwide scale-up of CHW interventions in a resource-challenged country. Identifying and understanding these barriers, and addressing them accordingly, particularly within the context of performance-based financing, will serve to strengthen the current CHW system and provide key guidance for the continuing evolution of the CHW system in Rwanda.
... However, the direct and indirect costs of marketing ITNs or using commercial distribution mechanisms may be barriers to equitable distribution. Although social marketing may not increase inequity for rural Africans (Nathan et al. 2004), alternative methods of subsidy or distribution are needed to improve coverage and equity (Gallup and Sachs 2001). ...
... The intervention did little to increase bednet ownership among the very poorest families where the price of even subsided nets was still too great a barrier. Conversely, in another bednet intervention in Tanzania, Nathan et al. (2004) found social marketing was associated with an increase in equity; the ratio of net ownership between poorest and richest households doubled over the three years of intervention. The authors note, however, that the existing demand for mosquito nets in these communities was already extremely high and this level of effect should not be assumed elsewhere in the absence of this important 'enabling' factor. ...
Article
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Health interventions increasingly rely on formative qualitative research and social marketing techniques to effect behavioural change. Few studies, however, incorporate qualitative research into the process of program evaluation to understand both impact and reach: namely, to what extent behaviour change interventions work, for whom, in what contexts, and why. We reflect on the success of a community-based hygiene intervention conducted in the slums of Kathmandu, Nepal, evaluating both maternal behaviour and infant health. We recruited all available mother-infant pairs (n = 88), and allocated them to control and intervention groups. Formative qualitative research on hand-washing practices included structured observations of 75 mothers, 3 focus groups, and 26 in-depth interviews. Our intervention was led by Community Motivators, intensively promoting hand-washing-with-soap at key junctures of food and faeces contamination. The 6-month evaluation period included hand-washing and morbidity rates, participant observation, systematic records of fortnightly community meetings, and follow-up interviews with 12 mothers. While quantitative measures demonstrated improvement in hand-washing rates and a 40% reduction in child diarrhoea, the qualitative data highlighted important equity issues in reaching the ultra-poor. We argue that a social marketing approach is inherently limited: focussing on individual agency, rather than structural conditions constraining behaviour, can unwittingly exacerbate health inequity. This contributes to a prevention paradox whereby those with the greatest need of a health intervention are least likely to benefit, finding hand-washing in the slums to be irrelevant or futile. Thus social marketing is best deployed within a range of interventions that address the structural as well as the behavioural and cognitive drivers of behaviour change. We conclude that critiques of social marketing have not paid sufficient attention to issues of health equity, and demonstrate how this can be addressed with qualitative data, embedded in both the formative and evaluative phases of a health intervention.
... This was also reflected by the wish of respondents to diminish the price of the ITN. This finding confirms the results from many observations in SSA countries where lack of sufficient funds was a main reason for not buying ITN [20,[29][30][31][32][33][34][35][36]. This observation supports the arguments of those in favour for free ITN distribution systems in SSA [9]. ...
Article
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Background: This study aims to describe the community perceptions regarding an insecticide-treated bed net (ITN) programme in Burkina Faso, where communities were randomised to either ITN social marketing combined with free ITN distribution through antenatal care services (intervention A) or ITN social marketing only (intervention B). Methods: For this descriptive qualitative study data were collected through a total of 20 focus group discussions (FGD), 10 FGD with women and men respectively. FGD were conducted in 8 purposefully selected villages of the study area and in Nouna town. Findings: The ITN free distribution was well known to and highly appreciated in the intervention area A. Awareness of the ITN social marketing distribution was however low in both intervention areas, except in the urban part (Nouna town) of intervention area B. Women were reported to be able to purchase ITNs independent of their husbands. Poverty and frequent unavailability of ITN for purchase were the main barriers for ITN ownership. ITN information was mainly received through personal communication with health workers and through radio messages. Conclusion: While the free ITN distribution was highly appreciated by the population, the social marketing approach alone appeared not be sufficient to reach the goal of high ITN coverage, mainly due to prevailing poverty and the insufficient availability of ITN for purchase.
... It was noted that previous evaluation by CARE Tanzania noted that the pregnant women who failed to top up the vouchers were denied the vouchers, and this is a disappointment to the women con-cerned and might have discouraged some women to attend clinic (ii) their confusion about and negative perception of the user-fee system. Already, the challenge facing pregnant women from poor households in accessing ITNs is already recognized41424344. The reported inability of some women to pay for the nets made the MOHSW to specify a uniform topping up price of 500/-shillings (US$0.4) per voucher [26]. ...
Article
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To describe the prospects, achievements, challenges and opportunities for implementing intermittent preventive treatment for malaria in pregnancy (IPTp) in Tanzania in light of national antenatal care (ANC) guidelines and ability of service providers to comply with them. In-depth interviews were made with national level malaria control officers in 2006 and 2007. Data was analysed manually using a qualitative content analysis approach. IPTp has been under implementation countrywide since 2001 and the 2005 evaluation report showed increased coverage of women taking two doses of IPTp from 29% to 65% between 2001 and 2007. This achievement was acknowledged, however, several challenges were noted including (i) the national antenatal care (ANC) guidelines emphasizing two IPTp doses during a woman's pregnancy, while other agencies operating at district level were recommending three doses, this confuses frontline health workers (HWs); (ii) focused ANC guidelines have been revised, but printing and distribution to districts has often been delayed; (iii) reports from district management teams demonstrate constraints related to women's late booking, understaffing, inadequate skills of most HWs and their poor motivation. Other problems were unreliable supply of free SP at private clinics, clean and safe water shortage at many government ANC clinics limiting direct observation treatment and occasionally pregnant women asked to pay for ANC services. Finally, supervision of peripheral health facilities has been inadequate and national guidelines on district budgeting for health services have been inflexible. IPTp coverage is generally low partly because IPTp is not systematically enforced like programmes on immunization, tuberculosis, leprosy and other infectious diseases. Necessary concerted efforts towards fostering uptake and coverage of two IPTp doses were emphasized by the national level officers, who called for further action including operational health systems research to understand challenges and suggest ways forward for effective implementation and high coverage of IPTp. The benefit of IPTp is appreciated by national level officers who are encouraged by trends in the coverage of IPTp doses. However, their appeal for concerted efforts towards IPTp scaling-up through rectifying the systemic constraints and operational research is important and supported by suggestions by other authors.
... The first strategy arguments that due to prevailing poverty ITNs should be considered as a public good like vaccines and consequently be provided through the public sector free of charge [5][6][7][8][9][10]. Others criticize this approach as being not sustainable due to its intrinsic need for excessive donor investment and rather favour the strengthening of commercial markets [9,[11][12][13][14]. Recently the two positions approached each other. ...
Article
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Insecticide-treated nets (ITNs) have been confirmed to be a very effective tool in malaria control. Two different delivery strategies for roll-out of ITN programmes have been the focus of debate in the last years: free distribution and distribution through commercial marketing systems. They are now seen as complementary rather than opponent. Acceptance of these programmes by the community and involved providers is an important aspect influencing their sustainability. This paper looks at how providers perceived, understood and accepted two interventions involving two different delivery strategies (subsidized sales supported by social marketing and free distribution to pregnant women attending antenatal care services). The interventions took place in one province of north-western Burkina Faso in 2006 in the frame of a large randomized controlled ITN intervention study. For this descriptive qualitative study data were collected through focus group discussions and individual interviews. A total of four focus group discussions and eleven individual interviews have been conducted with the providers of the study interventions. The free distribution intervention was well accepted and perceived as running well. The health care staff had a positive and beneficial view of the intervention and did not feel overwhelmed by the additional workload. The social marketing intervention was also seen as positive by the rural shopkeepers. However, working in market economy, shopkeepers feared the risk of unsold ITNs, due to the low demand and capacity to pay for the product in the community. The combination of ITN free distribution and social marketing was in general well accepted by the different providers. However, low purchasing power of clients and the resulting financial insecurities of shopkeepers remain a challenge to ITN social marketing in rural SSA.
... A factor, such as socio-economic status (SES), may be associated with several different heterogeneities. SES can influence transmission intensity through quality of housing, knowledge of protection measures and use of ITNs [5-8]. Risks of co-morbidity and malnutrition may be associated with SES [9,10]. ...
Article
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Individuals in a malaria endemic community differ from one another. Many of these differences, such as heterogeneities in transmission or treatment-seeking behaviour, affect malaria epidemiology. The different kinds of heterogeneity are likely to be correlated. Little is known about their impact on the shape of age-prevalence and incidence curves. In this study, the effects of heterogeneity in transmission, treatment-seeking and risk of co-morbidity were simulated. Simple patterns of heterogeneity were incorporated into a comprehensive individual-based model of Plasmodium falciparum malaria epidemiology. The different types of heterogeneity were systematically simulated individually, and in independent and co-varying pairs. The effects on age-curves for parasite prevalence, uncomplicated and severe episodes, direct and indirect mortality and first-line treatments and hospital admissions were examined. Different heterogeneities affected different outcomes with large effects reserved for outcomes which are directly affected by the action of the heterogeneity rather than via feedback on acquired immunity or fever thresholds. Transmission heterogeneity affected the age-curves for all outcomes. The peak parasite prevalence was reduced and all age-incidence curves crossed those of the reference scenario with a lower incidence in younger children and higher in older age-groups. Heterogeneity in the probability of seeking treatment reduced the peak incidence of first-line treatment and hospital admissions. Heterogeneity in co-morbidity risk showed little overall effect, but high and low values cancelled out for outcomes directly affected by its action. Independently varying pairs of heterogeneities produced additive effects. More variable results were produced for co-varying heterogeneities, with striking differences compared to independent pairs for some outcomes which were affected by both heterogeneities individually. Different kinds of heterogeneity both have different effects and affect different outcomes. Patterns of co-variation are also important. Alongside the absolute levels of different factors affecting age-curves, patterns of heterogeneity should be considered when parameterizing or validating models, interpreting data and inferring from one outcome to another.
... Until recently, most African countries recorded low levels of ITN coverage and wide inequities between the poor and the rich existed [13][14][15][16]. Between 1998 and 2002, ITN use among children under five years was less than 5% in 23 countries [17]. ...
Article
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Ensuring that the poor and vulnerable population benefit from malaria control interventions remains a challenge for malaria endemic countries. Until recently, ownership and use of insecticides treated nets (ITNs) in most countries was low and inequitable, although coverage has increased in countries where free ITN distribution is integrated into mass vaccination campaigns. In Kenya, free ITNs were distributed to children aged below five years in 2006 through two mass campaigns. High and equitable coverage were reported after the campaigns in some districts, although national level coverage remained low, suggesting that understanding barriers to access remains important. This study was conducted to explore barriers to ownership and use of ITNs among the poorest populations before and after the mass campaigns, to identify strategies for improving coverage, and to make recommendations on how increased coverage levels can be sustained. The study was conducted in the poorest areas of four malaria endemic districts in Kenya. Multiple data collection methods were applied including: cross-sectional surveys (n = 708 households), 24 focus group discussions and semi-structured interviews with 70 ITN suppliers. Affordability was reported as a major barrier to access but non-financial barriers were also shown to be important determinants. On the demand side key barriers to access included: mismatch between the types of ITNs supplied through interventions and community preferences; perceptions and beliefs on illness causes; physical location of suppliers and; distrust in free delivery and in the distribution agencies. Key barriers on the supply side included: distance from manufacturers; limited acceptability of ITNs provided through interventions; crowding out of the commercial sector and the price. Infrastructure, information and communication played a central role in promoting or hindering access. Significant resources have been directed towards addressing affordability barriers through providing free ITNs to vulnerable groups, but the success of these interventions depends largely on the degree to which other barriers to access are addressed. Only if additional efforts are directed towards addressing non-financial barriers to access, will high coverage levels be achieved and sustained.
... However, observed inequalities in ownership of bed nets across socio-economic groups in Mulanda suggest that, in order to dramatically increase universal coverage, the costs associated with acquiring a net must be reduced. Whilst there is debate surrounding the most appropriate approach to achieving equitable and sustainable ITN delivery [57][58][59][60][61][62], several studies have indicated that post-intervention inequalities in net use are lower following free distribution campaigns than following social marketing interventions [40,42,43]. Current distribution strategies in Uganda are focused on young children and pregnant women, following a mixed model that includes both the commercial sector and civil society organizations. ...
Article
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Malaria is a leading cause of disease burden in Uganda, although surprisingly few contemporary, age-stratified data exist on malaria epidemiology in the country. This report presents results from a total population survey of malaria infection and intervention coverage in a rural area of eastern Uganda, with a specific focus on how risk factors differ between demographic groups in this population. In 2008, a cross-sectional survey was conducted in four contiguous villages in Mulanda, sub-county in Tororo district, eastern Uganda, to investigate the epidemiology and risk factors of Plasmodium species infection. All permanent residents were invited to participate, with blood smears collected from 1,844 individuals aged between six months and 88 years (representing 78% of the population). Demographic, household and socio-economic characteristics were combined with environmental data using a Geographical Information System. Hierarchical models were used to explore patterns of malaria infection and identify individual, household and environmental risk factors. Overall, 709 individuals were infected with Plasmodium, with prevalence highest among 5-9 year olds (63.5%). Thin films from a random sample of 20% of parasite positive participants showed that 94.0% of infections were Plasmodium falciparum and 6.0% were P. malariae; no other species or mixed infections were seen. In total, 68% of households owned at least one mosquito although only 27% of school-aged children reported sleeping under a net the previous night. In multivariate analysis, infection risk was highest amongst children aged 5-9 years and remained high in older children. Risk of infection was lower for those that reported sleeping under a bed net the previous night and living more than 750 m from a rice-growing area. After accounting for clustering within compounds, there was no evidence for an association between infection prevalence and socio-economic status, and no evidence for spatial clustering. These findings demonstrate that mosquito net usage remains inadequate and is strongly associated with risk of malaria among school-aged children. Infection risk amongst adults is influenced by proximity to potential mosquito breeding grounds. Taken together, these findings emphasize the importance of increasing net coverage, especially among school-aged children.
... Interviews with different key informants in selected villages confirmed that the current high costs of ITNs are a major barrier impeding its wider use. In a recent study from Tanzania, social marketing has also been shown to increase equity in ITN use; three years after a social marketing campaign commenced, the ratio of net ownership between the poorest and the richest quintile increased from 0.3 to 0.6 (Nathan et al., 2004). Concluding, it is known that public spending on health care favours the better-off disproportionally, hence targeting equity cannot be solved only by adjusting subsidy allocations. ...
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Enthält versch. Sonderdr. Diss. Naturwiss. Basel (kein Austausch). Literaturverz. Universität, Basel
... Many of these gains must be credited to social marketing. In an rural area of Tanzania where social marketing had been rigorously promoted, Nathan et al [27] documented that the proportion of the poorest households with a bed net increased from less than a quarter in 1997 to more than a half in 2000 and an increase the ratio of 'any net in the household' between the poorest and least poor from 0.3 to 0.6. Coverage in our study area five years later showed a strikingly similar pattern and suggests a lag of several years between areas with intense promotion and those subject to the consequent national roll-out that in our study area has been supplemented by non-commercial distribution that accounted for a third of ITNs in the poorest households. ...
Article
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There is no clear consensus on the most sustainable and effective distribution strategy for insecticide treated bed nets (ITNs). Tanzania has been a leader in social marketing but it is still not clear if this can result in high and equitable levels of coverage. A cluster-randomized survey of ITN and bed net ownership and use was conducted in a rural area exposed to intense Plasmodium falciparum transmission in NE Tanzania where ITN distribution had been subject to routine delivery of national strategies and episodic free distribution through local clinics. Data were collected on household assets to assess equity of ITN coverage and a rapid diagnostic test for malaria (RDT) was performed in all ages. Among 598 households in four villages the use of any or insecticidal bed nets in children less than five years of age was 71% and 54% respectively. However there was a 19.8% increase in the number of bed nets per person (p < 0.001) and a 13.4% increase in the number of insecticidal nets per person (p < 0.001) for each quintile increase in household asset score. The odds of being RDT-positive were reduced by more than half in the least poor compared to the poorest households (OR 0.49, 95% CI 0.35-0.70). Poorer households had paid less for their nets and acquired them more recently, particularly from non-commercial sources, and bed nets in the least poor households were less likely to be insecticidal compared to nets in the poorest households (OR 0.44, 95% CI 0.26-0.74). Marked inequity persists with the poorest households still experiencing the highest risk of malaria and the lowest ITN coverage. Abolition of this inequity within the foreseeable future is likely to require mass or targeted free distribution, but risks damaging what is otherwise an effective commercial market.
... SMITN and KINET data suggest that affordability remains a significant obstacle to net use, especially for the poorest. Recent data confirm a socio-economically stratified gradient in treated and untreated net ownership and re-treatment rates [35,36], although this gap is narrowing over time. As household coverage rates increase overall, and with the beneficial effects of the TNVS, coverage should rapidly increase in the lower socio-economic quintiles and harder-to-reach rural areas. ...
Article
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Malaria is the largest cause of health services attendance, hospital admissions and child deaths in Tanzania. At the Abuja Summit in April 2000 Tanzania committed itself to protect 60% of its population at high risk of malaria by 2005. The country is, therefore, determined to ensure that sustainable malaria control using insecticide-treated nets is carried out on a national scale. Tanzania has been involved for two decades in the research process for developing insecticide-treated nets as a malaria control tool, from testing insecticides and net types, to assessing their efficacy and effectiveness, and exploring new ways of distribution. Since 2000, the emphasis has changed from a project approach to that of a concerted multi-stakeholder action for taking insecticide-treated nets to national scale (NATNETS). This means creating conditions that make insecticide-treated nets accessible and affordable to all those at risk of malaria in the country. This paper describes Tanzania's experience in (1) creating an enabling environment for insecticide-treated nets scale-up, (2) promoting the development of a commercial sector for insecticide-treated nets, and (3) targeting pregnant women with highly subsidized insecticide-treated nets through a national voucher scheme. As a result, nearly 2 million insecticide-treated nets and 2.2 million re-treatment kits were distributed in 2004. National upscaling of insecticide-treated nets is possible when the programme is well designed, coordinated and supported by committed stakeholders; the Abuja target of protecting 60% of those at high risk is feasible, even for large endemic countries.
... Marketing of ITNs or using commercial distribution mechanisms imposes direct and indirect costs that may be barriers to equitable distribution. Although social marketing may not increase inequity for rural African populations (Nathan et al. 2004), additional methods of subsidy or distribution are needed to address coverage and equity (Gallup & Sachs 2001). ...
Article
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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.
... The time taken to reach the facility was defined as the sum of reported travel, waiting and consultation times. Household socioeconomic status was scored using a principal components analysis on the list of household assets, as well as education and occupation variables, and then categorized in five groups from least poor to poorest of the poor (Nathan et al. 2004). ...
Article
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Catastrophic payments and fairness in financial contributions for health care are becoming increasing concerns for many governments. Out-of-pocket financing for health care is common in many developing countries, including Tanzania. As part of the Multi-Country Evaluation of the Integrated Management of Childhood Illness (MCE-IMCI), the objective of this paper is to explore the determinants of variation and the level of out-of-pocket payments for child health care in rural Tanzania, with and without IMCI, using data from two household surveys conducted in 1999 and 2002. We analyzed data for 833 visits to health providers for 764 children who had been sick in the 2 weeks prior to the survey and who had sought care at a 'Western' or formal health care provider. We found evidence that IMCI was associated with lower out-of-pocket costs at government facilities (Tshs.3.5 compared with Tshs.6.9 without IMCI) and in NGOs (Tshs.95.1 compared with Tshs.267.3). Out-of-pocket payments were on average Tshs.110.1 when care was sought at government primary health care facilities running a cost-sharing scheme, about 15 times higher than in those not part of the scheme (p<0.0001). Those who visited NGO facilities paid about 30 times more than those seeking care at government facilities not operating the cost-sharing scheme (p<0.0001). In conclusion, there is no doubt that health care financing mechanisms and equitable access to government facilities have a major impact on household economic burden related to under-five illness. Increasing access to IMCI-based care, however, offers an additional opportunity to reduce out-of-pocket payments, mainly through more rational use of medicines. Increasing access to IMCI-based care would not only improve inequities in financial contributions, but also in health, an important consideration for its own sake.
... In keeping with the paradigm that health beliefs underpin behaviour, many anthropologists have investigated the beliefs surrounding malaria and its transmission, as well as attitudes to mosquito nets and willingness to pay for them (e.g., Adongo, Kirkwood, & Kendall, 2005;Minja et al., 2001;Winch et al., 1994). Most recently, research has focused on ownership and inequities in access to nets, with increasing recognition of contextual constraints to purchase of nets and the need for enabling factors, such as vouchers and targeted subsidies for high-risk groups (Holtz et al., 2002;Mushi, Schellenberg, Mponda, & Lengeler, 2004;Nathan et al., 2004). The social ecological model proposed here synthesises all these important elements, and could serve as a useful framework in planning and evaluating programmes of malaria control. ...
Article
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Behaviour change is notoriously difficult to initiate and sustain, and the reasons why efforts to promote healthy behaviours fail are coming under increasing scrutiny. To be successful, health interventions should build on existing practices, skills and priorities, recognise the constraints on human behaviour, and either feature community mobilisation or target those most receptive to change. Furthermore, interventions should strive to be culturally compelling, not merely culturally appropriate: they must engage local communities and nestle within social and ecological landscapes. In this paper, we propose a social ecology perspective to make explicit the links between intention to change, actual behaviour change, and subsequent health impact, as relating to both theory-based models and practical strategies for triggering behaviour change. A social ecology model focuses attention on the contexts of behaviour when designing, implementing or critically evaluating interventions. As a case study, we reflect on a community-directed intervention in rural Gambia designed to reduce malaria by promoting a relatively simple and low-cost behaviour: repairing holes in mosquito bednets. In phase 1, contextual information on bednet usage, transactions and repairs (the 'social lives' of nets) was documented. In phase 2 (intervention), songs were composed and posters displayed by community members to encourage repairs, creating a sense of ownership and a compelling medium for the transmission of health messages. In phase 3 (evaluation), qualitative and quantitative data showed that household responses were particularly rapid and extensive, with significant increase in bednet repairs (p<0.001), despite considerable constraints on human agency. We highlight a promising approach-using songs-as a vehicle for change, and present a framework to embed the design, implementation and critical evaluation of interventions within the larger context-or social ecology-of behaviour practices that are the bedrock of health interventions.
... The epidemiology of malaria in the Kilombero Valley has been well described and a number of malaria control interventions, notably the KINET social marketing program for ITNs, have been evaluated in this setting [13,14,161718. The malaria transmission systems of this valley, and the village of Namwawala in particular, have been very well characterized, yielding a rich set of vector and parasite biodemographic parameters for detailed transmission modelling [19]. ...
Article
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African malaria vectors bite predominantly indoors at night so sleeping under an Insecticide-Treated Net (ITN) can greatly reduce malaria risk. Behavioural adaptation by mosquitoes to increasing ITN coverage could allow vector mosquitoes to bite outside of peak sleeping hours and undermine efficacy of this key malaria prevention measure. High coverage with largely untreated nets has been achieved in the Kilombero Valley, southern Tanzania through social marketing programmes. Direct surveys of nightly biting activity by An. gambiae Giles were conducted in the area before (1997) and after (2004) implementation of ITN promotion. A novel analytical model was applied to estimate the effective protection provided by an ITN, based on published experimental hut trials combined with questionnaire surveys of human sleeping behaviour and recorded mosquito biting patterns. An. gambiae was predominantly endophagic and nocturnal in both surveys: Approximately 90% and 80% of exposure occurred indoors and during peak sleeping hours, respectively. ITNs consistently conferred >70% protection against exposure to malaria transmission for users relative to non-users. As ITN coverage increases, behavioural adaptation by mosquitoes remains a future possibility. The approach described allows comparison of mosquito biting patterns and ITN efficacy at multiple study sites and times. Initial results indicate ITNs remain highly effective and should remain a top-priority intervention. Combined with recently developed transmission models, this approach allows rapid, informative and cost-effective preliminary comparison of diverse control strategies in terms of protection against exposure before more costly and intensive clinical trials.
... A comparison of nationally representative Demographic and Health Surveys data shows that urban-rural and socio-economic differentials in net use declined after the heavily subsidized net was introduced [11,12]. Another assessment of a social marketing intervention in 25 villages in Tanzania showed that, in the presence of an extremely active commercial sector for nets, social marketing of nets at a retail price of $5 was associated with an increased equity in ownership of nets [13]. This study assesses the effects of a hybrid social marketing intervention to increase knowledge, access and use of ITNs in a primarily rural province of Zambia. ...
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An ITN intervention was initiated in three predominantly rural districts of Eastern Province, Zambia, that lacked commercial distribution and communication infrastructures. Social marketing techniques were used for product and message development. Public sector clinics and village-based volunteers promoted and distributed subsidized ITNs priced at 2.5 dollars per net. A study was conducted to assess the effects of the intervention on inequities in knowledge, access, ownership and use of ITNs. A post-test only quasi-experimental study design was used to compare intervention and comparison districts. A total of 2,986 respondents were interviewed. Survey respondents were grouped into four socio-economic (SES) categories: low, medium-low, medium and high. Knowledge, access, ownership and use indicators are compared. Concentration index scores are calculated. Interactions between intervention status and SES help determine how different SES groups benefited from the intervention. Although overall use of nets remained relatively low, post-test data show that knowledge, access, ownership and use of mosquito nets was higher in intervention districts. A decline in SES inequity in access to nets occurred in intervention districts, resulting from a disproportionately greater increase in access among the low SES group. Declines in SES inequities in net ownership and use of nets were associated with the intervention. The largest increases in net ownership and use occurred among medium and high SES categories. Increasing access to nets among the poorest respondents in rural areas may not lead to increases in net use unless the price of nets is no longer a barrier to their purchase.
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The burdens of malaria on economic development of many tropical countries cannot be overemphasized. Introduction of ITN is a major effort by international bodies to reduce the problem. This study analysed the interrelationship between access to ITN and malaria morbidity. Data from the 2008 Demographic and Health Survey (DHS) were used and analyses were carried out using descriptive statistics and Two Stage Least Square. Results show that presence of pregnant women in the household, household size, north east, south east, and south south regions, number of children 5 years and under, age of household head, sex of household head, educational status, listening to radio, read newspaper, occupation, electricity, one room for sleeping in the household and marital status significantly influence access to ITN (p<0.10), while presence of a pregnant woman and number of children five years and under increased reported malaria morbidity. It was concluded that access to ITN may not translate into reduction of malaria morbidity, depending on the usage and exposure of household members to mosquito bites outside the nets. Efforts at reducing malaria morbidity should therefore focus on media interventions in providing complete information on malaria prevention.
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Objectives. To compare caregivers' knowledge and practice of key disease prevention household and community practices in two local government areas (LGAs), in one of which Community-Integrated Management of Childhood Illness (C-IMCI) had been implemented. Design. A cross-sectional design. Setting. Osun State, Nigeria, between August and September 2007. Subjects. Mothers or caregivers of children 0 - 59 months of age and their index children. Results. The IMCI key disease prevention practices were generally better applied in the C-IMCI-compliant LGA than in the non-compliant LGA. Significant differences were observed in the proportion of caregivers who would wash their hands with soap after using the toilet (p=0.0445), after attending to a child who has passed stool (p=0.000), before feeding a child (p=0.000), before preparing food (p=0.000), and before eating (p=0.0385). More caregivers from the compliant than the non-compliant LGA had ever used a method to prevent malaria. More than a quarter of caregivers from the non-compliant LGA did not use any method to prevent malaria. More caregivers from the non-compliant LGA showed deficiencies in their knowledge base of HIV/AIDS infection. Knowledge was particularly poor with respect to mother-to-child transmission of HIV. Only 39% of caregivers from the non-compliant LGA believed that a child can be infected with HIV/AIDS.
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Abstract Objective This study was conducted to know the prevailing common attitudes of clinicians in an emergency setup towards patients attempting suicide. Method A 34 item questionnaire which has been used in a previous similar study was used. The data was subjected to factor analysis. Results showed marked rejection, avoidance, hostility and indifference was found. Conclusion- various internal and external factors, interact to produce the negative attitude in the clinicians. The need for the better training, holistic and multidisciplinary approach is the call of the recent times. Keywords Suicide, DSH(Deliberate Self Harm), Clinicians attitudes, emergency setting
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This article addresses deep-seated problems in applying traditional relationship marketing and customer relationship management concepts in the context of social marketing. Further, it points out the recent changes in interactive technologies, culture, lifestyle, and the marketing logic and discusses the “makeover” of the concept and practices of the customer relationship management. It describes how the revised logic of marketing is more accommodative of social marketing and how the new avatar of customer relationship management 2.0 is more relevant for social marketers. It explains how the concepts and practices of customer relationship management 2.0, which are rooted in service logic, can be applied in the context of social marketing to co-create value. It explores the role of social marketers and their customers as active relationship partners and describes their interactions as a locus of value co-creations. Through these interactions, customers engage with social marketers to co-create different aspects of the market offerings, and social marketers engage in customers' value-generating processes to co-create better value-in-use. The key building blocks described in the article enable the value co-creations. The article concludes with implications in terms of how social marketers can use these insights to make the world a better place.
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Heparin-induced thrombocytopenia (HIT) is an adverse drug reaction caused by antibodies to the heparin/platelet factor 4 (PF4) complexes. HIT diagnosis is challenging and depends on clinical presentation and laboratory tests. We investigated the interest of the combined use of 4 Ts score and the functional and immunological tests for the diagnosis of HIT. We analyzed 178 patients with suspected HIT, for which the 4 Ts score was calculated. Heparin-PF4 antibodies were detected by both Heparin-induced platelet activation test (HIPA) and Heparin platelet induced antibodies enzyme immunoassay. Our results shown that in low probability group, 85% of plasmas were found negative versus 55.5% in the high probability group. On the other hand, 22.2% of patients were HIT positive in high probability group versus 0% in the low probability group. These results confirmed that the negative predictive value of the HIT score was high. The 4T's model has demonstrated excellent sensitivity but its specificity was limited. The specificity of the functional and immunological test is high only in a context suggestive of HIT. Both methods should be considered complementary in the diagnostic strategy.
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Insecticide-treated nets (ITNs) are effective in substantially reducing malaria transmission. Still, ITN coverage in sub-Saharan Africa (SSA) remains extremely low. Policy makers are concerned with identifying the most suitable delivery mechanism to achieve rapid yet sustainable increases in ITN coverage. Little is known, however, on the comparative costs of alternative ITN distribution strategies. This paper aimed to fill this gap in knowledge by developing such a comparative cost analysis, looking at the cost per ITN distributed for two alternative interventions: subsidized sales supported by social marketing and free distribution to pregnant women through antenatal care (ANC). The study was conducted in rural Burkina Faso, where the two interventions were carried out alongside one another in 2006/07. Cost information was collected prospectively to derive both a financial analysis adopting a provider's perspective and an economic analysis adopting a societal perspective. The average financial cost per ITN distributed was US$8.08 and US$7.21 for sales supported by social marketing and free distribution through ANC, respectively. The average economic cost per ITN distributed was US$4.81 for both interventions. Contrary to common belief, costs did not differ substantially between the two interventions. Due to the district's ability to rely fully on the use of existing resources, financial costs associated with free ITN distribution through ANC were in fact even lower than those associated with the social marketing campaign. This represents an encouraging finding for SSA governments and points to the possibility to invest in programmes to favour free ITN distribution through existing health facilities. Given restricted budgets, however, free distribution programmes are unlikely to be feasible.
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If the United Nations Millennium Development Goals are to be met, there is a need to improve access to effective antimalarial treatment where the burden of malaria is highest. Health facilities are often bypassed by communities, and inappropriate and poor-quality self-medication is common. The home management of malaria (HMM) strategy has been shown to have an effect on malaria morbidity and mortality in the chloroquine era, but several evidence gaps remain to be filled to confirm its value in the era of artemisinin-based combination therapies. Nevertheless, if a substantial reduction of the malaria burden is to be achieved, access to effective medicines has to be vastly improved, and in most of sub-Saharan Africa, this will have to be through HMM.
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The coverage of insecticide-treated nets (ITNs) remains low despite existing distribution strategies, hence, it was important to assess consumers' preferences for distribution of ITNs, as well as their perceptions and expenditures for malaria prevention and to examine the implications for scaling-up ITNs in rural Nigeria. Nine focus group discussions (FGDs) and questionnaires to 798 respondents from three malaria hyper-endemic villages from Enugu state, south-east Nigeria were the study tools. There was a broad spectrum of malaria preventive tools being used by people. The average monthly expenditure on malaria prevention per household was 55.55 Naira ($0.4). More than 80% of the respondent had never purchased any form of untreated mosquito net. People mostly preferred centralized community-based sales of the ITNS, with installment payments. People were knowledgeable about malaria and the beneficial effects of using nets to protect themselves from the disease. The mostly preferred community-based distribution of ITNs implies that the strategy is a potential untapped additional channel for scaling-up ITNs in Nigeria and possibly other parts of sub-Saharan Africa.
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To determine levels of socioeconomic inequities in the prevention of malaria, and to examine the implications of the findings for improving the equitable control of malaria in the Sudan. A cross-sectional survey using a pre-tested interviewer-administered questionnaire was administered to 720 randomly selected householders from six localities in Gezira and Khartoum States. A socioeconomic status (SES) index, which was developed using principal components analysis, was used to examine socioeconomic inequity in the prevention of malaria. Socioeconomic status was positively related to expenditures and use of vector control tools. The poorest households spent the least amounts of money to prevent malaria and were the least likely to own mosquito nets. The inequity in the prevention of malaria in the study areas has to be redressed before malaria can be effectively controlled in Sudan. Malaria control managers should continually determine the extent to which malaria preventive tools reach the poorest socioeconomic groups, and fashion strategies that will ensure that equity is always maintained.
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To assess malaria prevalence rates and seasonal patterns among clinically diagnosed malaria cases at the level of primary care facilities in an urban Sahelian setting. Screening all patients consulting two private and two governmental providers on a randomly selected weekday over a period of 9 months. Patients with presumptive malaria underwent a blood test. Of 1658 patients included in the survey, 47% were clinically diagnosed and treated as malaria cases. Malaria was more often diagnosed by private providers. There were no clear seasonal patterns in presumptive malaria. A 30% of clinically diagnosed cases were positive for Plasmodium (all falciparum) by thick film examination. Thus, false positive cases constituted more than 70% of the clinically diagnosed malaria cases. The highest positive prevalence rates were found at the end and shortly after the rainy season (44%-47%) and the lowest during the dry season (2%). Clinical diagnosis of malaria has a very low positive predicted value in this low endemicity urban setting, and its low specificity leads to inappropriate care for a large proportion of patients. This has a major impact on economic costs for health services and households. In the Sahel, systematic use of microscopy-based diagnosis and/or rapid diagnostic tests should be considered to appropriately manage malaria and non-malaria cases.
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Malaria, a parasitic infection, causes hundreds of millions of disease episodes and more than a million deaths every year, nearly all of them occurring in the poorer and more vulnerable sectors of the world's developing countries. In spite of the great burden of suffering caused by malaria, the human rights implications of this disease have not been well described. This article summarizes important associations between the spread of malaria and human rights abuses (such as those associated with slavery and armed conflict) and between poverty, socio-economic inequity, and access to malaria-control measures. The author concludes that malaria control merits inclusion as a core element in global strategies to achieve progressive realization of the right to health.
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Malaria and poverty are intimately connected. Controlling for factors such as tropical location, colonial history, and geographical isolation, countries with intensive malaria had income levels in 1995 of only 33% that of countries without malaria, whether or not the countries were in Africa. The high levels of malaria in poor countries are not mainly a consequence of poverty. Malaria is geographically specific. The ecological conditions that support the more efficient malaria mosquito vectors primarily determine the distribution and intensity of the disease. Intensive efforts to eliminate malaria in the most severely affected tropical countries have been largely ineffective. Countries that have eliminated malaria in the past half century have all been either subtropical or islands. These countries' economic growth in the 5 years after eliminating malaria has usually been substantially higher than growth in the neighboring countries. Cross-country regressions for the 1965-1990 period confirm the relationship between malaria and economic growth. Taking into account initial poverty, economic policy, tropical location, and life expectancy, among other factors, countries with intensive malaria grew 1.3% less per person per year, and a 10% reduction in malaria was associated with 0.3% higher growth. Controlling for many other tropical diseases does not change the correlation of malaria with economic growth, and these diseases are not themselves significantly negatively correlated with economic growth. A second independent measure of malaria has a slightly higher correlation with economic growth in the 1980-1996 period. We speculate about the mechanisms that could cause malaria to have such a large impact on the economy, such as foreign investment and economic networks within the country.
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To assess the costs and consequences of a social marketing approach to malaria control in children by means of insecticide-treated nets in two rural districts of the United Republic of Tanzania, compared with no net use. Project cost data were collected prospectively from accounting records. Community effectiveness was estimated on the basis of a nested case-control study and a cross-sectional cluster sample survey. The social marketing approach to the distribution of insecticide-treated nets was estimated to cost 1560 US dollars per death averted and 57 US dollars per disability-adjusted life year averted. These figures fell to 1018 US dollars and 37 US dollars, respectively, when the costs and consequences of untreated nets were taken into account. The social marketing of insecticide-treated nets is an attractive intervention for preventing childhood deaths from malaria.
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Introduction: Social Marketing: A Powerful Approach to Social Change PREPARING FOR SOCIAL MARKETING Putting the Customer First: The Essential Social Marketing Insight The Social Marketing Strategic Management Process Listening to Customers: Research for Social Marketing Understanding How Customer Behavior Changes DOING SOCIAL MARKETING Targeting Your Customer Through Market Segmentation Strategies Bringing the Customer to the Door: Creating Active Contemplation of New Behaviors Making the New Behavior Attractive and Low Cost: Benefit and Cost Strategies Bringing Social Influence to Bear and Enhancing Self-Control Inducing Action and Ensuring Maintenance Creating Strategic Partnerships: Marketing to Other Publics Conclusion: Central Principles of the New Social Marketing Paradigm.
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Since 1997 the WHO has been recommending an integrative strategy to combat malaria including new medicines, vaccines, improvements of health care systems and insecticide-treated nets (ITNs). After successful controlled trials with ITNs in the past decade, large-scale interventions and research now focus on operational issues of distribution and financing. In developing a social marketing approach in the Kilombero Valley in south-east Tanzania in 1996, a combination of qualitative and quantitative methods was employed to investigate local knowledge and practice relating to malaria. The findings show that the biomedical concept of malaria overlaps with several local illness concepts, one of which is called maleria and refers to mild malaria. Most respondents linked maleria to mosquitoes (76%) and already used mosquito nets (52%). But local understandings of severe malaria differed from the biomedical concept and were not linked to mosquitoes or malaria. A social marketing strategy to promote ITNs was developed on the basis of these findings, which reinforced public health messages and linked them with nets and insecticide. Although we did not directly evaluate the impact of promotional activities, the sharp rise in ownership and use of ITNs by the population (from 10 to > 50%) suggests that they contributed significantly to the success of the programme. Local knowledge and practice is highly relevant for social marketing strategies of ITNs.
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This paper has an empirical and overtly methodological goal. The authors propose and defend a method for estimating the effect of household economic status on educational outcomes without direct survey information on income or expenditures. They construct an index based on indicators of household assets, solving the vexing problem of choosing the appropriate weights by allowing them to be determined by the statistical procedure of principal components. While the data for India cannot be used to compare alternative approaches they use data from Indonesia, Nepal, and Pakistan which have both expenditures and asset variables for the same households. With these data the authors show that not only is there a correspondence between a classification of households based on the asset index and consumption expenditures but also that the evidence is consistent with the asset index being a better proxy for predicting enrollments--apparently less subject to measurement error for this purpose--than consumption expenditures. The relationship between household wealth and educational enrollment of children can be estimated without expenditure data. A method for doing so - which uses an index based on household asset ownership indicators- is proposed and defended in this paper. In India, children from the wealthiest households are over 30 percentage points more likely to be in school than those from the poorest households.
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All the 32 member states in the World Health Organization European Region adopted a common health policy in 1980), followed by unanimous agreement on 38 regional targets in 1984. The first of these targets is concerned with equity. Target 1: “By the year 2000, the actual differences in health status between countries and between groups within countries should be reduced by at least 25%, by improving the level of health of disadvantaged nations and groups” (WHO, 1985a). In addition, equity is an underlying concept in many of the other targets. At present, the targets are being reassessed and revised, in particular moving away from a focus on physical health status as measured by mortality to encompass, wherever possible, many other dimensions of health and well-being. But still the underlying concept of equity in health has been judged to be just as important for the 1990s as it was when the programme began (WHO, 1985b). However, it has not always been clear what is meant by equity and health and this paper sets out to clarify the concepts and principles. This is not meant to be a technical document, but one aimed at raising awareness and stimulating debate in a wide general audience, including all those whose policies have an influence on health, both within and outside the health sector.
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We present a large-scale social marketing programme of insecticide-treated nets in 2 rural districts in southwestern Tanzania (population 350,000) and describe how the long-term child health and survival impact will be assessed. Formative and market research were conducted in order to understand community perceptions, knowledge, attitudes and practice with respect to the products to be socially marketed. We identified Zuia Mbu (Kiswahili for 'prevent mosquitoes') as a suitable brand name for both treated nets and single-dose insecticide treatment sachets. A mix of public and private sales outlets is used for distribution. In the first stage of a stepped introduction 31 net agents were appointed and trained in 18 villages: 15 were shop owners, 14 were village leaders, 1 was a parish priest and 1 a health worker. For net treatment 37 young people were appointed in the same villages and trained as agents. Further institutions in both districts such as hospitals, development projects and employers were also involved in distribution. Promotion for both products was intense and used a variety of channels. A total of 22,410 nets and 8072 treatments were sold during the first year: 18 months after launching, 46% of 312 families with children aged under 5 years reported that their children were sleeping under treated nets. A strong evaluation component in over 50,000 people allows assessment of the long-term effects of insecticide-treated nets on child health and survival, anaemia in pregnancy, and the costs of the intervention. This evaluation is based on cross-sectional surveys, and case-control and cohort studies.
Article
There is considerable international concern that child-health inequities seem to be getting worse between and within richer and poorer countries. The "inverse equity hypothesis" is proposed to explain how such health inequities may get worse, remain the same, or improve over time. We postulate that as new public-health interventions and programmes initially reach those of higher socioeconomic status and only later affect the poor, there are early increases in inequity ratios for coverage, morbidity, and mortality indicators. Inequities only improve later when the rich have achieved new minimum achievable levels for morbidity and mortality and the poor gain greater access to the interventions. The hypothesis was examined using three epidemiological data sets for time trends in child-health inequities within Brazil. Time trends for inequity ratios for morbidity and mortality, which were consistent with the hypothesis, showed both improvements and deterioration over time, despite the indicators showing absolute improvements in health status between rich and poor.
Article
Using data from India, we estimate the relationship between household wealth and children's school enrollment. We proxy wealth by constructing a linear index from asset ownership indicators, using principal-components analysis to derive weights. In Indian data this index is robust to the assets included, and produces internally coherent results. State-level results correspond well to independent data on per capita output and poverty. To validate the method and to show that the asset index predicts enrollments as accurately as expenditures, or more so, we use data sets from Indonesia, Pakistan, and Nepal that contain information on both expenditures and assets. The results show large, variable wealth gaps in children's enrollment across Indian states. On average a "rich" child is 31 percentage points more likely to be enrolled than a "poor" child, but this gap varies from only 4.6 percentage points in Kerala to 38.2 in Uttar Pradesh and 42.6 in Bihar.
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
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.
Socioeconomic differences in health, nutrition and population in Tanzania Available at: http://www.worldbank.org/poverty/health/data/tanzania/tanzania
  • Dr Gwatkin
  • S Rustein
  • K Johnson
  • Pande
  • A Wagstaff
  • Dr Gwatkin
  • S Rustein
  • K Johnson
  • Pande
  • A Wagstaff
Marketing Social Change: Changing Beha-viour to Promote Health, Social Development, and the Envi-ronment. Jossey-Bass KINET: a social marketing programme of treated nets and net treatment for malaria control in Tanzania, with evaluation of child health and long-term survival
  • Armstrong Andreasen
  • Jrm Schellenberg
  • S Abdulla
  • Minja
Andreasen AR (1995) Marketing Social Change: Changing Beha-viour to Promote Health, Social Development, and the Envi-ronment. Jossey-Bass, San Francisco, CA. Armstrong Schellenberg JRM, Abdulla S, Minja H et al. (1999) KINET: a social marketing programme of treated nets and net treatment for malaria control in Tanzania, with evaluation of child health and long-term survival. Transactions of the Royal Society of Tropical Medicine and Hygiene 93, 225–231.
Population and Health in Developing Countries. Population, Health and Sur-vival at INDEPTH Sites
  • Dss Ifakara
  • Tanzania
INDEPTH (2002) Ifakara DSS, Tanzania. In: Population and Health in Developing Countries. Population, Health and Sur-vival at INDEPTH Sites, Vol. 1. (eds Sankoh O, Kahn K, Mwageni E, Ngom P & Nyarko P). IDRC, Ottawa, pp. 159– 164.
Reducing health inequalities in developing countries In: Oxford Textbook of Public Health
  • Gwatkin
  • R Detels
  • J Mcewen
  • R Beaglehole
  • H Tanaka
  • Oxford
  • Uni
Gwatkin D (2002) Reducing health inequalities in developing countries. In: Oxford Textbook of Public Health, 4th edn (eds Detels R, McEwen J, Beaglehole R & Tanaka H) Oxford Uni-versity Press, Oxford, pp. 1791–1810.
Social Marketing of Insecticide Treated Mosquito Nets, Tanzania. End of phase 1 social and economic analysis. Technical assistance to PSI Tanzania, final report
  • Hanson
  • Jones
Hanson K & Jones C (2000) Social Marketing of Insecticide Treated Mosquito Nets, Tanzania. End of phase 1 social and economic analysis. Technical assistance to PSI Tanzania, final report, June 2000. Malaria Consortium, London.
Social Marketing of Insecticide Treated Mosquito Nets, Tanzania. End of phase 1 social and economic analysis
  • K Hanson
  • C Jones
Hanson K & Jones C (2000) Social Marketing of Insecticide Treated Mosquito Nets, Tanzania. End of phase 1 social and economic analysis. Technical assistance to PSI Tanzania, final report, June 2000. Malaria Consortium, London.
Insecticide-treated bed nets and curtains for preventing malaria (Cochrane Review) In: The Cochrane Library , Issue 1. Update Software
  • C Lengeler
Lengeler C (2001) Insecticide-treated bed nets and curtains for preventing malaria (Cochrane Review). In: The Cochrane Library, Issue 1. Update Software, Oxford.
The African Summit on Roll Back Malaria
  • Roll Back Malaria
Roll Back Malaria (2000) The African Summit on Roll Back Malaria, Abuja, Nigeria, April 25th, 2000. (WHO/CDS/RBM/ 2000.17) WHO, Geneva. 68 pp.
Tanzania Reproductive and Child Health Survey
National Bureau of Statistics (2000) Tanzania Reproductive and Child Health Survey, 1999. National Bureau of Statistics and Macro International Inc., Calverton, MD.
Scaling-up insecticide-treated netting materials in Africa. A strategic framework for coordinated national action
  • Roll Back Malaria
Roll Back Malaria (2002) Scaling-up insecticide-treated netting materials in Africa. A strategic framework for coordinated national action. http://mosquito.who.int/cmc_upload/0/000/ 015/845/itn_programmes.pdf
Insecticide Treated Net Projects: a Handbook for Managers. Malaria Consortium
  • D Chavasse
  • C Reed
  • K Attawell
Chavasse D, Reed C & Attawell K (1999) Insecticide Treated Net Projects: a Handbook for Managers. Malaria Consortium, London and Liverpool.
Economic analysis of social marketing and commercial sector insecticide treated nets delivery models in rural communities of Tanzania
  • N Kikumbih
Kikumbih N (2002) Economic analysis of social marketing and commercial sector insecticide treated nets delivery models in rural communities of Tanzania. PhD Thesis, University of London.
Socioeconomic differences in health, nutrition and population in Tanzania Available at
  • Dr Gwatkin
  • S Rustein
  • K Johnson
  • Rp Pande
  • A Wagstaff
Socioeconomic differences in health, nutrition and population in Tanzania
  • Dr Gwatkin
  • Rustein
  • Johnson
  • A Rp Pande
  • Wagstaff
Gwatkin DR, Rustein S, Johnson K, Pande RP & Wagstaff A (2000) Socioeconomic differences in health, nutrition and population in Tanzania. World Bank, May 2000. Available at: http://www.worldbank.org/poverty/health/data/tanzania/tanzania.pdf (accessed on 29 January 2002).
Swiss Tropical Institute
  • Don De Savigny
  • Christian Lengeler
  • Marcel Tanner
Don de Savigny, Christian Lengeler and Marcel Tanner, Swiss Tropical Institute, Postfach. 4200 Basel, Switzerland. E-mail: d.desavigny@unibas.ch, christian.lengeler@unibas.ch, marcel.tanner@unibas.ch
  • Curtis CF