A little good is good enough: Ethical consumption, cheap excuses, and moral self-licensing.

This paper explores the role of cheap excuses in product choice. If agents feel that they fulfill one ethical aspect, they may care less about other independent ethical facets within product choice. Choosing a product that fulfills one ethical aspect may then suffice for maintaining a high moral self-image in agents and render it easier to ignore other ethically relevant aspects they would otherwise care about more. The use of such cheap excuses could thus lead to a "static moral self-licensing" effect, and this would extend the logic of the well-known dynamic moral self-licensing. Our experimental study provides empirical evidence that the static counterpart of moral self-licensing exists. Furthermore, effects spill over to unrelated, ethically relevant contexts later in time. Thus, static moral self-licensing and dynamic moral self-licensing can exist next to each other. However, it is critical that agents do not feel that they fulfilled an ethical criterion out of sheer luck, that is, agents need some room so that they can attribute the ethical improvement at least partly to themselves. Outsiders, although monetarily incentivized for correct estimates, are completely oblivious to the effects of moral self-licensing, both static and dynamic.

Effects of winter housing systems on production, economics, body weight, body condition score, and bedding cultures for organic dairy cows.

Certified-organic dairy cows (n = 268) were used to evaluate the effect of 2 winter (December to April) housing systems on milk production, somatic cell score (SCS), body weight, body condition score (BCS), and economics across 3 winter seasons (2013, 2014, and 2015). Bedding cultures from the housing systems were also evaluated. Cows were randomly assigned to 2 treatments (2 replicates per group): (1) outdoor (straw pack, n = 140) or (2) indoor (3-sided compost bedded pack barn, n = 128). Cows calved during 2 seasons (spring or fall) at the University of Minnesota West Central Research and Outreach Center, Morris, Minnesota, organic dairy. Milk, fat, and protein production and SCS were recorded from monthly milk recording. Body weight and BCS were recorded biweekly as cows exited the milking parlor. Bedding cultures from the housing systems were collected biweekly. Costs for key inputs and the price received for milk production were recorded for the study period and averaged for use in the profitability analysis. Energy-corrected milk and SCS were not different for the outdoor (15.1 kg/d, 2.64) and indoor (15.7 kg/d, 2.57) housing systems, respectively. In addition, cows in the outdoor and indoor housing systems were not different for body weight (528 vs. 534 kg) and BCS (3.22 vs. 3.23), respectively. Daily dry matter intake was 19.1 kg/d for the outdoor cows and 19.6 kg/d for indoor cows. The total bacteria count from bedding samples tended to be lower in the outdoor (13.0 log10 cfu/mL) compared with the indoor (14.9 log10 cfu/mL) system. Milk revenue and feed cost were not different for the 2 housing systems. Labor and bedding costs were lower and net return was higher for the outdoor housing system. The outdoor straw pack system had a $1.42/cow per day net return advantage over the indoor compost bedded pack barn. In summary, lactating cows housed outdoors on straw-bedded packs did not differ for production or SCS, or for body weight, BCS, or dry matter intake, but had greater profitability than cows housed in an indoor compost bedded pack barn.

[The effectiveness of a system using re-useable linens to reduce the expense of surgical operations].

We introduced a system that uses re-useable linens for surgical operations in 2008. After 3 years from introduction we were able to reduce the expense of about yen 4,340,000 per year and CO2 production of 9,548 kg CO2 x m(-2) per year. We were convinced of the effect on reducing the expense of surgical operations and of decreasing the level of CO2 production that leads to global warming.

A survey of surgical draping practices in small-animal practice in the UK.

Veterinary practices in the United Kingdom were surveyed to compare their surgical draping practices with Royal College of Veterinary Surgeons (RCVS) accreditation tier and other surgery-related factors. Using descriptive statistics and logistic or ordinal regression analysis (where appropriate), the relationships between draping material and accreditation tier and other surgery-related factors were assessed. Procedures were categorised as short or long. Two hundred and sixty-nine surveys were completed. Reusable drapes were used in 66 per cent of practices. Antibiotics were administered routinely in 38 per cent of short and 93 per cent of long procedures. Practices accredited as a Veterinary Hospital (VH) were 6.3-7.2 (short and long surgeries, respectively) times more likely to use disposable drapes, when compared with non-accredited practices. Use of dedicated surgical attire, draping the whole animal/table, and routine antibiotic usage were also positively correlated with disposable drape usage. Fifty-one per cent of practices rated infection rate as most important when choosing drape material. 'Best practice' techniques are associated with lower importance given to infection rate, and higher importance given to financial cost, when choosing drape material. Disposable drape use correlates with RCVS accreditation and with other aspects of surgical technique. Importance ratings awarded correlate with best practice procedures. Clinical relevance 'Best practice' draping procedures, that are not governed by RCVS accreditation scheme, are also more frequently performed in accredited VHs.

Management and characteristics of recycled manure solids used for bedding in Midwest freestall dairy herds.

Interest in using recycled manure solids (RMS) as a bedding material for dairy cows has grown in the US Midwest. Cost of common bedding materials has increased in recent years and availability has decreased. Information regarding the composition of RMS and its use as a bedding material for dairy cows in the Midwest is very limited. The objectives of this study were to characterize RMS as a bedding material, observe bedding management practices, document methods of obtaining RMS, and describe housing facilities. We visited 38 Midwest dairy operations bedding freestalls with RMS to collect data. Methods of obtaining RMS for bedding included separation of anaerobic digested manure, separation of raw manure, and separation of raw manure followed by mechanical drum-composting for 18 to 24 h. Average bedding moisture of unused RMS was 72.4% with a pH of 9.16. Unused samples contained (on a dry basis) 1.4% N, 44.9% C, 32.7C:N ratio, 0.44% P, 0.70% K, 76.5% neutral detergent fiber, 9.4% ash, 4.4% nonfiber carbohydrates, and 1.1% fat. Moisture was lowest for drum-composted solids before and after use as freestall bedding. After use in the stalls, digested solids had lower neutral detergent fiber content (70.5%) than drum-composted (75.0%) and separated raw (73.1%) solids. Total N content was greater in digested solids (2.0%) than in separated raw (1.7%) solids. Total bacterial populations in unused bedding were greatest in separated raw manure solids but were similar between digested and drum-composted manure solids. Drum-composted manure solids had no coliform bacteria before use as freestall bedding. After use as bedding, digested manure solids had lower total bacteria counts compared with drum-composted and separated raw manure solids, which had similar counts. Used bedding samples of digested solids contained fewer environmental streptococci than drum-composted and separated raw solids and had reduced Bacillus counts compared with separated raw solids. Coliform counts were similar for all 3 bedding sources. Addition of a mechanical blower post-separation and use of a shelter for storage were associated with reduced fresh-bedding moisture but not associated with bacterial counts. This was the first survey of herds using RMS for bedding in the Midwest. We learned that RMS was being used successfully as a source of bedding for dairy cows. For most farms in the study, somatic cell count was comparable to the average in the region and not excessively high.

Design, implementation and evaluation of a national campaign to distribute nine million free LLINs to children under five years of age in Tanzania.

BACKGROUND: After a national voucher scheme in 2004 provided pregnant women and infants with highly subsidized insecticide-treated nets (ITNs), use among children under five years (U5s) in mainland Tanzania increased from 16% in 2004 to 26.2% in 2007. In 2008, the Ministry of Health and Social Welfare planned a catch-up campaign to rapidly and equitably deliver a free long-lasting insecticidal net (LLIN) to every child under five years in Tanzania. METHODS: The ITN Cell, a unit within the National Malaria Control Programme (NMCP), coordinated the campaign on behalf of the Ministry of Health and Social Welfare. Government contractors trained and facilitated local government officials to supervise village-level volunteers on a registration of all U5s and the distribution and issuing of LLINs. The registration results formed the basis for the LLIN order and delivery to village level. Caregivers brought their registration coupons to village issuing posts during a three-day period where they received LLINs for their U5s. Household surveys in five districts assessed ITN ownership and use immediately after the campaign. RESULTS: Nine donors contributed to the national campaign that purchased and distributed 9.0 million LLINs at an average cost of $7.07 per LLIN, including all campaign-associated activities. The campaign covered all eight zones of mainland Tanzania, the first region being covered separately during an integrated measles immunization/malaria LLIN distribution in August 2008, and was implemented one zone at a time from March 2009 until May 2010. ITN ownership at household level increased from Tanzania's 2008 national average of 45.7% to 63.4%, with significant regional variations. ITN use among U5s increased from 28.8% to 64.1%, a 2.2-fold increase, with increases ranging from 22.1-38.3% percentage points in different regions. CONCLUSION: A national-level LLIN distribution strategy that fully engaged local government authorities helped avoid additional burden on the healthcare system. Distribution costs per net were comparable to other public health interventions. Particularly among rural residents, ITN ownership and use increased significantly for the intended beneficiaries. The upcoming universal LLIN distribution and further behaviour change communication will further improve ITN ownership and use in 2010-2011.

Possession and usage of insecticidal bed nets among the people of Uganda: is BRAC Uganda Health Programme pursuing a pro-poor path?

BACKGROUND: The use of insecticidal bed nets is found to be an effective public health tool for control of malaria, especially for under-five children and pregnant women. BRAC, an indigenous Bangladeshi non-governmental development organization, started working in the East African state of Uganda in June 2006. As part of its efforts to improve the health and well-being of its participants, BRAC Uganda has been distributing long lasting insecticide-treated bed nets (LLIN) at a subsidized price through health volunteers since February 2008. This study was conducted in March-April 2009 to examine how equitable the programme had been in consistence with BRAC Uganda's pro-poor policy. METHODOLOGY/PRINCIPAL FINDINGS: Information on possession of LLINs and relevant knowledge on its proper use and maintenance was collected from households either with an under-five child and/or a pregnant woman. The sample included three villages from each of the 10 branch offices where BRAC Uganda's community-based health programme was operating. Data were collected by trained enumerators through face-to-face interviews using a hand-held personal digital assistant (PDA). Findings reveal that the study population had superficial knowledge on malaria and its transmission, including the use and maintenance of LLINs. The households' rate of possession of bed nets (41-59%), and the proportion of under-five children (17-19%) and pregnant women (25-27%) who reported sleeping under an LLIN were not encouraging. Inequity was observed in the number of LLINs possessed by the households, in the knowledge on its use and maintenance, and between the two programme areas. CONCLUSIONS/SIGNIFICANCE: The BRAC Uganda's LLINs distribution at a subsidized price appeared to be inadequate and inequitable, and BRAC's knowledge dissemination is insufficient for initiating preventive actions such as proper use of LLINs to interrupt malaria transmission. Findings contribute to the on-going debate on LLINs distribution in Africa and make a strong case for its free distribution.

System effectiveness of a targeted free mass distribution of long lasting insecticidal nets in Zanzibar, Tanzania.

BACKGROUND: Insecticide-treated nets (ITN) and long-lasting insecticidal treated nets (LLIN) are important means of malaria prevention. Although there is consensus regarding their importance, there is uncertainty as to which delivery strategies are optimal for dispensing these life saving interventions. A targeted mass distribution of free LLINs to children under five and pregnant women was implemented in Zanzibar between August 2005 and January 2006. The outcomes of this distribution among children under five were evaluated, four to nine months after implementation. METHODS: Two cross-sectional surveys were conducted in May 2006 in two districts of Zanzibar: Micheweni (MI) on Pemba Island and North A (NA) on Unguja Island. Household interviews were conducted with 509 caretakers of under-five children, who were surveyed for socio-economic status, the net distribution process, perceptions and use of bed nets. Each step in the distribution process was assessed in all children one to five years of age for unconditional and conditional proportion of success. System effectiveness (the accumulated proportion of success) and equity effectiveness were calculated, and predictors for LLIN use were identified. RESULTS: The overall proportion of children under five sleeping under any type of treated net was 83.7% (318/380) in MI and 91.8% (357/389) in NA. The LLIN usage was 56.8% (216/380) in MI and 86.9% (338/389) in NA. Overall system effectiveness was 49% in MI and 87% in NA, and equity was found in the distribution scale-up in NA. In both districts, the predicting factor of a child sleeping under an LLIN was caretakers thinking that LLINs are better than conventional nets (OR = 2.8, p = 0.005 in MI and 2.5, p = 0.041 in NA), in addition to receiving an LLIN (OR = 4.9, p < 0.001 in MI and in OR = 30.1, p = 0.001 in NA). CONCLUSIONS: Targeted free mass distribution of LLINs can result in high and equitable bed net coverage among children under five. However, in order to sustain high effective coverage, there is need for complimentary distribution strategies between mass distribution campaigns. Considering the community's preferences prior to a mass distribution and addressing the communities concerns through information, education and communication, may improve the LLIN usage.

Preferences of dairy cows for three stall surface materials with small amounts of bedding.

Farmers' concerns about the economy, cost of labor, and hygiene have resulted in reduced use of organic bedding in stalls for dairy cows; however, the reduced use of organic bedding possibly impairs cow comfort. The effects of different stall surface materials were evaluated in an unheated building in which only a small amount of bedding was used. The lying time and preferences of 18 cows using 3 stall surface materials (concrete, soft rubber mat, and sand) were compared. All materials were lightly bedded with a small amount of straw, and the amount of straw added to each stall was measured. The cows only had access to stalls of one surface type while their lying time was observed. Lying times were longest on the rubber mats compared with other surfaces (rubber mat 768; concrete 727; sand 707+/-16 min/d). In a preference test, cows had access to 2 of the 3 types of stalls for 10 d and their stall preference was measured. Cows preferred stalls with rubber mats to stalls with a concrete floor (median 73 vs. 18 from a total of 160 observations per day; interquartile range was 27 and 12, respectively), but showed no preference for sand stalls compared with stalls with a concrete floor or with rubber mats. More straw was needed on sand stalls compared with concrete or mat (638+/-13 g/d on sand, 468+/-10 g/d on concrete, and 464+/-8 g/d on rubber mats). Lying times on bedded mats indicated that mats were comfortable for the cows. If availability or cost of bedding material requires limiting the amount of bedding used, rubber mats may help maintain cow comfort.

Cost-effectiveness of adding bed net distribution for malaria prevention to antenatal services in Kinshasa, Democratic Republic of the Congo.

We evaluated the cost-effectiveness of distributing insecticide-treated bed nets (ITNs) for malaria prevention at antenatal clinics in Kinshasa, Democratic Republic of the Congo. A decision tree model was used to estimate costs, outcomes, and incremental cost-effectiveness for 17,893 pregnant women attending 28 antenatal clinics who received long-lasting ITNs free of charge. Costs including purchase, transportation, storage, and distribution of ITNs were derived from program records. The ITN efficacy and other parameters were derived from peer-reviewed literature. Outcomes modeled included low birth weight (LBW) deliveries, infant deaths averted, life-years saved (LYs), and disability-adjusted life-years (DALYs) averted. Deterministic and probabilistic sensitivity analyses were conducted. For the 17,893 women in our program, ITN distribution would be expected to avert 587 LBW deliveries and 414 infant deaths. The incremental cost-effectiveness was US $17.22 per DALY averted (95% confidence interval [CI] = US $8.54-$30.90), US $15.70 per LY saved (95% CI = US $7.65-$27.68), and US $411.13 per infant death averted (95% CI = US $353.95-$1,085.89). If resources were constrained, the greatest benefit would be among women in their first through fourth pregnancies. Thus, ITN distribution is a cost-effective addition to antenatal services.

Household ownership and use of insecticide treated nets among target groups after implementation of a national voucher programme in the United Republic of Tanzania: plausibility study using three annual cross sectional household surveys.

OBJECTIVES: To evaluate the impact of the Tanzania National Voucher Scheme on the coverage and equitable distribution of insecticide treated nets, used to prevent malaria, to pregnant women and their infants. DESIGN: Plausibility study using three nationally representative cross sectional household and health facility surveys, timed to take place early, mid-way, and at the end of the roll out of the national programme. SETTING: The Tanzania National Voucher Scheme was implemented in antenatal services, and phased in on a district by district basis from October 2004 covering all of mainland Tanzania in May 2006. PARTICIPANTS: 6115, 6260, and 6198 households (in 2005, 2006, and 2007, respectively) in a representative sample of 21 districts (out of a total of 113). INTERVENTIONS: A voucher worth $2.45 ( pound1.47, euro1.74) to be used as part payment for the purchase of a net from a local shop was given to every pregnant woman attending antenatal services. MAIN OUTCOME MEASURES: Insecticide treated net coverage was measured as household ownership of at least one net and use of a net the night before the survey. Socioeconomic distribution of nets was examined using an asset based index. RESULTS: Steady increases in net coverage indicators were observed over the three year study period. Between 2005 and 2007, household ownership of at least one net (untreated or insecticide treated) increased from 44% (2686/6115) to 65% (4006/6198; P<0.001), and ownership of at least one insecticide treated net doubled from 18% (1062/5961) to 36% (2229/6198) in the same period (P<0.001). Among infants under 1 year of age, use of any net increased from 33% (388/1180) to 56% (707/1272; P<0.001) and use of an insecticide treated net increased from 16% (188/1180) to 34% (436/1272; P<0.001). After adjusting for potential confounders, household ownership was positively associated with time since programme launch, although this association did not reach statistical significance (P=0.09). Each extra year of programme operation was associated with a 9 percentage point increase in household insecticide treated net ownership (95% confidence interval -1.6 to 20). In 2005, only 7% (78/1115) of nets in households with a child under 1 year of age had been purchased with a voucher; this value increased to 50% (608/1211) in 2007 (P<0.001). In 2007, infants under 1 year in the least poor quintile were more than three times more likely to have used an insecticide treated net than infants in the poorest quintile (54% v 16%; P<0.001). CONCLUSIONS: The Tanzania National Voucher Scheme was associated with impressive increases in the coverage of insecticide treated nets over a two year period. Gaps in coverage remain, however, especially in the poorest groups. A voucher system that facilitates routine delivery of insecticide treated nets is a feasible option to "keep up" coverage.

Integration of insecticide-treated net distribution into routine immunization services in Malawi: a pilot study.

OBJECTIVES: To determine the feasibility of distributing insecticide-treated nets (ITNs) through routine immunization services, to increase ownership and use of ITNs among high-risk groups, whereas maintaining or improving timely completion of routine vaccinations. METHODS: Free ITNs were provided with timely completion of routine vaccinations in two intervention districts in southern Malawi for 15 months. Cross-sectional baseline and follow-up household surveys were conducted in the two intervention districts and one control district. RESULTS: Insecticide-treated nets utilization among children aged 12-23 months roughly doubled in the two intervention districts and did not change in the control district. Timely vaccination coverage increased in all three districts. The percentage of children aged 12-23 months who were both fully vaccinated by 12 months and slept under an ITN the night prior to the interview increased from 10-14% at baseline to 40-44% at follow-up in the intervention districts (P < 0.001), but did not change significantly in the control district. CONCLUSIONS: This study is the first to evaluate the provision of free ITNs at completion of a child's primary vaccination series, demonstrating that such a linkage is both feasible and can result in improved coverage with the combined services. Additional studies are needed to determine whether such a model is effective in other countries, and whether integration of other health services with immunization delivery could also be synergistic.

From malaria control to eradication: The WHO perspective.

Efforts to control malaria have been boosted in the past few years with increased international funding and greater political commitment. Consequently, the reported malaria burden is being reduced in a number of countries throughout the world, including in some countries in tropical Africa where the burden of malaria is greatest. These achievements have raised new hopes of eradicating malaria. This paper summarizes the outcomes of a World Health Organization's expert meeting on the feasibility of such a goal. Given the hindsight and experience of the Global Malaria Eradication Programme of the 1950s and 1960s, and current knowledge of the effectiveness of antimalarial tools and interventions, it would be feasible to effectively control malaria in all parts of the world and greatly reduce the enormous morbidity and mortality of malaria. It would also be entirely feasible to eliminate malaria from countries and regions where the intensity of transmission is low to moderate, and where health systems are strong. Elimination of malaria requires a re-orientation of control activity, moving away from a population-based coverage of interventions, to one based on a programme of effective surveillance and response. Sustained efforts will be required to prevent the resurgence of malaria from where it is eliminated. Eliminating malaria from countries where the intensity of transmission is high and stable such as in tropical Africa will require more potent tools and stronger health systems than are available today. When such countries have effectively reduced the burden of malaria, the achievements will need to be consolidated before a programme re-orientation towards malaria elimination is contemplated. Malaria control and elimination are under the constant threat of the parasite and vector mosquito developing resistance to medicines and insecticides, which are the cornerstones of current antimalarial interventions. The prospects of malaria eradication, therefore, rest heavily on the outcomes of research and development for new and improved tools. Malaria control and elimination are complementary objectives in the global fight against malaria.

Malaria prevention in north-eastern Tanzania: patterns of expenditure and determinants of demand at the household level.

OBJECTIVE: This study aims to provide a better understanding of the amounts spent on different malaria prevention products and the determinants of these expenditures. METHODS: 1,601 households were interviewed about their expenditure on malaria mosquito nets in the past five years, net re-treatments in the past six months and other expenditures prevention in the past two weeks. Simple random sampling was used to select villages and streets while convenience sampling was used to select households. Expenditure was compared across bed nets, aerosols, coils, indoor spraying, using smoke, drinking herbs and cleaning outside environment. FINDINGS: 68% of households owned at least one bed net and 27% had treated their nets in the past six months. 29% were unable to afford a net. Every fortnight, households spent an average of US $0.18 on nets and their treatment, constituting about 47% of total prevention expenditure. Sprays, repellents and coils made up 50% of total fortnightly expenditure (US$0.21). Factors positively related to expenditure were household wealth, years of education of household head, household head being married and rainy season. Poor quality roads and living in a rural area had a negative impact on expenditure. CONCLUSION: Expenditure on bed nets and on alternative malaria prevention products was comparable. Poor households living in rural areas spend significantly less on all forms of malaria prevention compared to their richer counterparts. Breaking the cycle between malaria and poverty is one of the biggest challenges facing malaria control programmes in Africa.

Equity and coverage of insecticide-treated bed nets in an area of intense transmission of Plasmodium falciparum in Tanzania.

BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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.

Costs and cost-effectiveness of vector control in Eritrea using insecticide-treated bed nets.

BACKGROUND: While insecticide-treated nets (ITNs) are a recognized effective method for preventing malaria, there has been an extensive debate in recent years about the best large-scale implementation strategy. Implementation costs and cost-effectiveness are important elements to consider when planning ITN programmes, but so far little information on these aspects is available from national programmes. METHODS: This study uses a standardized methodology, as part of a larger comparative study, to collect cost data and cost-effectiveness estimates from a large programme providing ITNs at the community level and ante-natal care facilities in Eritrea. This is a unique model of ITN implementation fully integrated into the public health system. RESULTS: Base case analysis results indicated that the average annual cost of ITN delivery (2005 USD 3.98) was very attractive when compared with past ITN delivery studies at different scales. Financing was largely from donor sources though the Eritrean government and net users also contributed funding. The intervention's cost-effectiveness was in a highly attractive range for sub-Saharan Africa. The cost per DALY averted was USD 13 - 44. The cost per death averted was USD 438-1449. Distribution of nets coincided with significant increases in coverage and usage of nets nationwide, approaching or exceeding international targets in some areas. CONCLUSION: ITNs can be cost-effectively delivered at a large scale in sub-Saharan Africa through a distribution system that is highly integrated into the health system. Operating and sustaining such a system still requires strong donor funding and support as well as a functional and extensive system of health facilities and community health workers already in place.

Estimating inequalities in ownership of insecticide treated nets: does the choice of socio-economic status measure matter?

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.