Who buys nets? Factors associated with ownership and use of purchased mosquito nets in sub-Saharan Africa.

BACKGROUND: Public sector strategies to promote insecticide-treated net (ITN) access have resulted in increased ITN ownership across sub-Saharan Africa. However, the current status of the private sector distribution channel for nets has not been fully explored. This multi-country study explored the prevalence of net purchases and the characteristics of households that had purchased nets and used such nets in sub-Saharan Africa. METHODS: Data from recent Malaria Indicator Survey (MIS) or Demographic and Health Survey (DHS) in 16 countries were analysed to explore the prevalence of purchased nets. Purchased nets were defined as nets obtained from shops/markets or pharmacies. Additional sub-analysis of factors associated with ownership and use of purchased nets was conducted in seven countries with over 10% of nets reported as purchased. Key outcomes included: prevalence of purchased nets out of all nets, household ownership of a purchased net, and whether a purchased net was used the previous night. Analytical methods included country level tests of association and multivariable logistic regressions. RESULTS: Among all nets, the proportion of purchased nets in the study countries ranged from 0.8 to 32.7% and most (median = 77%) of these purchased nets were ITNs. Although the private nets are presumed to be from the retail, non-public sector, the prevalence of treated purchased nets suggests that some purchased nets may be "leaked" ITNs from public sector distributions, and thus, may be an informal sector rather than part of the formal "private sector". Urban, wealthier households as well as those with educated heads were more likely to own purchased nets. Use of such nets was, however, lower in wealthier households. In addition, net use was higher in households owning insufficient nets for their family size, and when the nets were newer than 24 months. CONCLUSION: The formal and informal private sector have played a role in bolstering net access rates in some settings. Study findings can help relevant malaria control stakeholders gain insight on the contribution of purchased nets on their overall ITN strategy, identify potential target populations for private sector nets as well as inform the design and distribution of private sector insecticide-treated nets that appeal to their target groups.

Age and gender trends in insecticide-treated net use in sub-Saharan Africa: a multi-country analysis.

BACKGROUND: The degree to which insecticide-treated net (ITN) supply accounts for age and gender disparities in ITN use among household members is unknown. This study explores the role of household ITN supply in the variation in ITN use among household members in sub-Saharan Africa. METHODS: Data was from Malaria Indicator Surveys or Demographic and Health Surveys collected between 2011 and 2016 from 29 countries in sub-Saharan Africa. The main outcome was ITN use the previous night. Other key variables included ITN supply (nets/household members), age and gender of household members. Analytical methods included logistic regressions and meta-regression. RESULTS: Across countries, the median (range) of the percentage of households with enough ITNs was 30.7% (8.5-62.0%). Crude analysis showed a sinusoidal pattern in ITN use across age groups of household members, peaking at 0-4 years and again around 30-40 years and dipping among people between 5-14 and 50+ years. This sinusoidal pattern was more pronounced in households with not enough ITNs compared to those with enough ITNs. ITN use tended to be higher in females than males in households with not enough ITNs while use was comparable among females and males in households with enough ITNs. After adjusting for wealth quintile, residence and region, among households with not enough ITNs in all countries, the odds of ITN use were consistently higher among children under 5 years and non-pregnant women 15-49 years. Meta-regressions showed that across all countries, the mean adjusted odds ratio (aOR) of ITN use among children under 5 years, pregnant and non-pregnant women aged 15-49 years and people 50 years and above was significantly higher than among men aged 15-49 years. Among these household members, the relationship was attenuated when there were enough ITNs in the household (dropping 0.26-0.59 points) after adjusting for geographical zone, household ITN supply, population ITN access, and ITN use:access ratio. There was no significant difference in mean aOR of ITN use among school-aged children compared to men aged 15-49 years, regardless of household ITN supply. CONCLUSIONS: This study demonstrated that having enough ITNs in the household increases level of use and decreases existing disparities between age and gender groups. ITN distribution via mass campaigns and continuous distribution channels should be enhanced as needed to ensure that households have enough ITNs for all members, including men and school-aged children.

Evaluation of a continuous community-based ITN distribution pilot in Lainya County, South Sudan 2012-2013.

BACKGROUND: Continuous distribution of insecticide-treated nets (ITNs) has now been accepted as one way of sustaining ITN universal coverage. Community-based channels offer an interesting means of delivering ITNs to households to sustain universal ITN coverage. The objective of this study was to provide proof of concept for this channel. METHODS: A 9-month, community-based, distribution pilot was implemented beginning 1 year after a mass campaign in Lainya County, South Sudan from 2012 to 2013. Following social mobilization, community members could request an ITN from a net coupon holder. Eligibility criteria included having lost an ITN, giving birth outside of the health facility, or not having enough ITNs for all household members. After verification, households could exchange the coupon for an ITN at a distribution point. The evaluation was a pre/post design using representative household surveys with two-stage cluster sampling and a sample size of 600 households per survey. RESULTS: At endline, 78% of respondents were aware of the scheme and 89% of those also received an ITN through community-based distribution. Population access to ITNs nearly doubled, from 38% at baseline to 66% after the pilot. Household ownership of any ITN and enough ITNs (1 for 2 people) also increased significantly, from 66 to 82% and 19 to 46%, respectively. Community-based distribution was the only source of ITNs for 53.4% of households. The proportion of the population using an ITN last night increased from 22.7% at baseline to 53.9% at endline. A logistic regression model indicates that although behaviour change communication was positively associated with an increase in ITN use, access to enough nets was the greatest determinant of use. CONCLUSIONS: ITN access and use improved significantly in the study area during the pilot, coming close to universal coverage targets. This pilot serves as proof of concept for the community-based distribution methodology implemented as a mechanism to sustain ITN universal coverage. Longer periods of implementation should be evaluated to determine whether community-based distribution can successfully maintain ITN coverage beyond the short term, and reach all wealth quintiles equitably.

Evaluation of community-based continuous distribution of long-lasting insecticide-treated nets in Toamasina II District, Madagascar.

BACKGROUND: Continuous distribution of insecticide-treated nets (ITNs) is thought to be an effective mechanism to maintain ITN ownership and access between or in the absence of mass campaigns, but evidence is limited. A community-based ITN distribution pilot was implemented and evaluated in Toamasina II District, Madagascar, to assess this new channel for continuous ITN distribution. METHODS: Beginning 9 months after the December 2012 mass campaign, a community-based distribution pilot ran for an additional 9 months, from September 2013 to June 2014. Households requested ITN coupons from community agents in their village. After verification by the agents, households exchanged the coupon for an ITN at a distribution point. The evaluation was a two-stage cluster survey with a sample size of 1125 households. Counterfactual ITN ownership and access were calculated by excluding ITNs received through the community pilot. RESULTS: At the end of the pilot, household ownership of any ITN was 96.5%, population access to ITN was 81.5 and 61.5% of households owned at least 1 ITN for every 2 people. Without the ITNs provided through the community channel, household ownership of any ITN was estimated at 74.6%, population access to an ITN at 55.5%, and households that owned at least 1 ITN for 2 people at only 34.7%, 18 months after the 2012 campaign. Ownership of community-distributed ITNs was higher among the poorest wealth quintiles. Over 80% of respondents felt the community scheme was fair and simple to use. CONCLUSIONS: Household ITN ownership and population ITN access exceeded RBM targets after the 9-month community distribution pilot. The pilot successfully provided coupons and ITNs to households requesting them, particularly for the least poor wealth quintiles, and the scheme was well-perceived by communities. Further research is needed to determine whether community-based distribution can sustain ITN ownership and access over the long term, how continuous availability of ITNs affects household net replacement behaviour, and whether community-based distribution is cost-effective when combined with mass campaigns, or if used with other continuous channels instead of mass campaigns.

Multi-country comparison of delivery strategies for mass campaigns to achieve universal coverage with insecticide-treated nets: what works best?

BACKGROUND: The use of insecticide-treated nets (ITNs) is widely recognized as one of the main interventions to prevent malaria. High ITN coverage is needed to reduce transmission. Mass distribution campaigns are the fastest way to rapidly scale up ITN coverage. However, the best strategy to distribute ITNs to ensure household coverage targets are met is still under debate. This paper presents results from 14 post-campaign surveys in five African countries to assess whether the campaign strategy used had any effect on distribution outcome. METHODS: Data from 13,901 households and 14 campaigns from Ghana, Nigeria, Senegal, South Sudan and Uganda, were obtained through representative cross-sectional questionnaire surveys, conducted three to 16 months after ITN distribution. All evaluations used a multi-stage sampling approach and similar methods for data collection. Key outcomes examined were the proportion of households having received a net from the campaign and the proportion of households with one net for every two people. RESULTS: Household registration rates proved to be the most important determinant of a household receiving any net from the campaign (adjusted odds ratio [OR] 74.8; 95 % confidence interval [CI]: 55.3-101.1) or had enough ITNs for all household members (adjusted OR 19.1; 95 % CI: 55.34-101.05). Factors that positively influenced registration were larger household size (adjusted OR 1.7; 95 % CI: 1.5-2.1) and families with children under five (adjusted OR 1.4; 95 % CI: 1.2-1.6). Urban residence was negatively associated with receipt of a net from the campaign (adjusted OR 0.73; 95 % CI: 0.58-0.92). Registration was equitable in most campaigns except for Uganda and South Sudan, where the poorest wealth quintiles were less likely to have been reached. After adjusting for other factors, delivery strategy (house-to-house vs. fixed point) and distribution approach (integrated versus stand-alone) did not show a systematic impact on registration or owning any ITN. Campaigns that used a universal coverage allocation strategy were more effective in increasing the proportion of households with enough ITNs than campaigns that used a fixed number of ITNs. Registering based on counting usual sleeping spaces resulted in higher levels of households with one net per two people among those receiving any campaign net (adjusted OR 1.6; 95 % CI: 1.07-2.48) than campaigns that registered based on the number of household members. CONCLUSION: All of the campaigns, irrespective of strategy, successfully increased ownership of at least one ITN. Delivery method and distribution approach were not associated with receipt of at least one ITN from the campaign. Rather, the key determining factor for receipt of at least one ITN from the campaign was a successful registration process, which depends on the ability of community volunteers to reach households during the exercise. Universal coverage campaigns, especially those that used a sleeping space allocation strategy, were more effective in increasing the proportion of households with enough ITNs. Maximizing registration completeness and using a universal coverage allocation strategy are therefore likely to improve campaign outcomes.

Impact of a behaviour change communication programme on net durability in eastern Uganda.

BACKGROUND: The importance of net durability and the average useful life of a net is increasingly recognized as one of the critical factors that determine how often nets need to be replaced. A study to assess the effect of a net care and repair behaviour change communication (BCC) programme on net durability was conducted in one district in Eastern Uganda with a district in a neighbouring region serving as a comparison. Both districts had received LLINs in September of 2012. METHODS: The intervention was comprised of radio programmes, school and community events. Two-stage cluster sampling household surveys to assess net condition, exposure to BCC messages, and attitudes towards net care and repair were conducted in both districts at baseline (2-3 months post net distribution) and endline (20-21 months post distribution). Net condition was assessed using the proportionate hole index, with nets being classified as either serviceable or too torn. RESULTS: The intervention led to an additional 31.2 % increased exposure to net care and repair messages in the intervention district. Respondents in the intervention district had a more positive attitude towards net care and repair (32 % of respondents were classified as having a very positive attitude compared to 10 % in the comparison district), which was positively associated with the number of channels through which messages had been received (P < 0.001). Nets belonging to respondents with a very positive attitude were more often categorized as serviceable (80.2 %) compared to respondents with a poor/average attitude (66.4 %; odds ratio: 2.05, P = 0.028); however, this was only observed for the net brand with the greater physical integrity. Additionally, socio-economic status was a significant predictor of net condition. Although nets in the intervention district had significantly more repairs done per net, the act of repairing alone did not improve net condition. CONCLUSIONS: In conclusion, the evaluation showed that the BCC programme resulted in improved knowledge and attitudes towards care and repair, which impacted positively on net condition. Repairs alone were not sufficient to improve net condition. Additional research on which care behaviours and attitudes are most associated with improved net condition would help BCC planners hone their campaigns.

Challenges in linking health research to policy: a commentary on developing a multi-stakeholder response to orphans and vulnerable children in Ghana.

The Research and Development Division (RDD) of the Ghana Health Service (GHS) has a remit to build research capacity and conduct policy relevant research. By being situated within the GHS, RDD has good access to directors and programme managers, within and beyond the Ministry of Health. This structure has been facilitating collaboration through research cycles for 20 years, from agenda setting to discussions on policy relevance.This approach has been applied to research activities within the Addressing the Balance of Burden in AIDS (ABBA) Research Programme Consortium to tackle the challenges facing HIV affected orphans and vulnerable children (OVCs). The government strategy on OVCs recommends they should be encouraged to live in their home communities rather than in institutions. We present lessons here on efforts to use research to build a response across different agencies to address the problems that communities and families face in caring for these children in their communities.This approach to building consensus on research priorities points to the value of collaboration and dialogue with multiple stakeholders as a means of fostering ownership of a research process and supporting the relevance of research to different groups. Our experience has shown that if the context within which researchers, policy makers and stakeholders work were better understood, the links between them were improved and research were communicated more effectively, then better policy making which links across different sectors may follow. At the same time, collaboration among these different stakeholders to ensure that research meets social needs, must also satisfy the requirements of scientific rigour.

Community trial of insecticide-treated bed net use promotion in southern Ghana: the Net Use Intervention study.

Insecticide-treated nets (ITNs) reduce malaria transmission and related morbidity and child mortality; however, incorrect and inconsistent use limits their protective factors. This community trial titled the Net Use Intervention study sought to bridge the gap between ITN ownership and use in southern (coastal) Ghana and to determine the best mix of communication tools to affect behavior of ITN owners to consistent use while maintaining optimal internal and external validity. This two-group, non-randomized experiment evaluated a multichannel, multisector intervention process over the course of 8 weeks. A longitudinal cohort was scientifically sampled from six intervention and six control communities for both baseline and posttest surveys. The posttest survey showed no change in knowledge of ITNs in the intervention or control. In terms of use the previous night, there was a strong and statistically significant intervention effect (OR = 1.67; p < .05) within the intervention communities. The overall increase in ITN coverage was approximately one person per night per every two households. The promotion efforts succeeded well beyond the planners' expectations, not only promoting usage but also dramatically increasing demand for new ITNs.