Strategies to increase the ownership and use of insecticide-treated bednets to prevent malaria

Changes in online marketing and sales practices among non-medical cannabis retailers in 5 US cities, 2022 to 2023

Objectives

Given the evolving cannabis marketplace (e.g., products, marketing strategies), this study examined online cannabis marketing practices over time.

Methods

In 2022 and 2023, researchers assessed website content (e.g., age verification, sales, delivery, warnings, ad content, promotional strategies) among 175 randomly-selected cannabis retailers' websites across 5 US cities (Denver, Colorado; Seattle, Washington; Portland, Oregon; Las Vegas, Nevada; Los Angeles [LA], California, n=∼35/city). Analyses compared data from 2022 vs. 2023 and considered regulatory factors across cities.

Results

Similar to 2022, in 2023, 76.6 % required age verification for site entry, 85.1 % used social media promotion, and 90.9 % offered online sales (82.4 % of which required age verification and 34.6 % offered delivery). There were significant (p < .05) decreases from 2022 to 2023 in the proportions indicating medical card requirements (27.4 % to 15.4 %), purchase limits (59.4 % to 47.4 %), health warnings (38.9 % to 29.7 %), health benefits (60 % to 47.4 %), and discounts/price promotions (92.6 % to 86.3 %). In 2023, proportions differed across cities in ways reflecting whether state/local law allowed online sales (>90 % in Denver, Las Vegas, LA), allowed discounts/price promotions (100 % in Denver and Las Vegas), or required health warnings (48-60 % in Seattle and LA vs. < 20 % elsewhere). Despite all sites prohibiting youth-oriented content and all but Denver and Las Vegas prohibiting health claims, 30.3 % posted content targeting youth/young adults (LA = 8.1 % to Denver = 74.2 %) and 47.4 % health claims (Seattle = 27.0 % to Denver = 71.0 %).

Conclusions

Online cannabis retail presents risks for access and appeal to minors, emphasizes health benefits, and uses price promotions, regardless of restrictions, indicating need for greater regulatory efforts.

Long-lasting household damage from Cyclone Idai increases malaria risk in rural western Mozambique

Cyclone Idai in 2019 was one of the worst tropical cyclones recorded in the Southern Hemisphere. The storm caused catastrophic damage and led to a humanitarian crisis in Mozambique. The affected population suffered a cholera epidemic on top of housing and infrastructure damage and loss of life. The housing and infrastructure damage sustained during Cyclone Idai still has not been addressed in all affected communities. This is of grave concern because storm damage results in poor housing conditions which are known to increase the risk of malaria. Mozambique has the 4th highest malaria prevalence in sub-Saharan Africa and is struggling to control malaria in most of the country. We conducted a community-based cross-sectional survey in Sussundenga Village, Manica Province, Mozambique in December 2019-February 2020. We found that most participants (64%) lived in households that sustained damage during Cyclone Idai. The overall malaria prevalence was 31% measured by rapid diagnostic test (RDT). When controlling for confounding variables, the odds of malaria infection was nearly threefold higher in participants who lived in households damaged by Cyclone Idai nearly a year after the storm. This highlights the need for long-term disaster response to improve the efficiency and success of malaria control efforts.

Assessment of Online Marketing and Sales Practices Among Recreational Cannabis Retailers in Five U.S. Cities

Background: With more states legalizing recreational cannabis, examining cannabis retail and marketing is crucial, as it may influence consumers' perceptions and behaviors. Particularly understudied is online cannabis retail. Methods: In Spring 2022, coders collected and analyzed data regarding retailer characteristics, age verification, and marketing strategies (e.g., product availability, health-related content, promotions, website imagery) among 195 cannabis retail websites in five U.S. cities (Denver, Colorado; Seattle, Washington; Portland, Oregon; Las Vegas, Nevada; Los Angeles, California). Descriptive analyses characterized the websites overall and across cities. Results: Overall, 80.5% verified age for website entry, and 92.8% offered online purchases (92.3% of retailers in Seattle, where prohibited). Of these, 82.9% required age verification for purchases, and 30.9% offered delivery. Almost all (>92%) offered flower/bud, concentrates, edibles, vaping devices, topicals, and tinctures. Health warnings were displayed on 38.3% of websites. Although all five states required health warnings regarding use during pregnancy, only 10.3% had these warnings. In addition, 59.0% posted some unsubstantiated health claims, most often indicating physical and mental health benefits (44.6%). Although Colorado, Washington, and Oregon prohibit health claims, 51.2-53.8% of these retailers posted them. Discounts, samples, or promotions were present on 90.8% of websites; 63.6% had subscription/membership programs. Subpopulations represented in website content included the following: 27.2% teens/young adults, 26.2% veterans, 7.2% sexual/gender minorities, and 5.6% racial/ethnic minorities. Imagery also targeted young people (e.g., 29.7% party/cool/popularity, 18.5% celebrity/influencer endorsement). Conclusions: Regulatory efforts are needed to better monitor promotional strategies and regulatory compliance (e.g., health claims, youth-oriented content, underage access) among online cannabis retailers.

Effects of Door-to-Door Hang-Up Visits on the Use of Long-Lasting Insecticide-Treated Mosquito Nets in the Democratic Republic of the Congo: A Cluster Randomized Controlled Trial

Malaria accounts for 14% of child deaths in the Democratic Republic of the Congo, and one of the key interventions used to prevent malaria is to distribute insecticide-treated bednets (ITNs), especially long-lasting insecticidal nets (LLINs). The global health community and the Roll Back Malaria initiative have been struggling to achieve universal health coverage using ITNs, and recent studies have reported mixed results about the effects of door-to-door visits and mass distribution campaigns. We aimed to compare LLIN use for those provided by door-to-door hang-up visits and by conventional fixed distribution from distribution centers accompanied by a mass distribution campaign. A cluster randomized control trial was conducted in rural areas of Maniema Province, Democratic Republic of the Congo (DR Congo). Cross-sectional surveys were conducted on 2120 and 2156 households, respectively, with at least one child aged less than five in 76 villages. We assessed the effectiveness of door-to-door hang-up visits on the use of LLINs by exploring the interaction between the “intervention group” and “time” using generalized estimating equation models. Increased LLINs use was observed in all age groups in both arms, but usage differences were not significantly different (relative risk (RR) of LLINs use among children < 5 in the intervention group versus the control group after adjusted for clustering: 1.06, 95% CI: 0.85–1.33). We conclude that the door-to-door hang-up visits are not sufficient to persuade individuals (pregnant woman, children < 5, or all study participants) to use LLINs, although it did appear to be effective for the youngest children in the household.

Coverage, determinants of use and repurposing of long-lasting insecticidal nets two years after a mass distribution in Lihir Islands, Papua New Guinea: a cross-sectional study

BACKGROUND

Universal coverage with long-lasting insecticidal nets (LLINs) is an essential component of malaria control programmes. Three-yearly mass distribution of LLINs in Papua New Guinea (PNG) has been successful in reducing infection transmission since 2009, but malaria prevalence ramped up from 2015 onwards. Although LLIN universal coverage is mostly achieved during these campaigns, it may not be related with net use over time. Uses given to LLINs and non-compliance of this strategy were evaluated.

METHODS

A knowledge, attitude and practice (KAP) cross-sectional study was conducted in Lihir Islands, PNG, 2-2.5 years after the last LLIN mass distribution campaign. Data on bed net ownership, use and maintenance behaviour was collected using a household questionnaire administered by trained community volunteers. Logistic regression models were used to identify factors associated with owning at least one LLIN and sleeping under a LLIN the previous night.

RESULTS

Among 2694 households surveyed, 27.4 % (95 % CI: 25.8-29.2) owned at least one LLIN and 8.7 % (95 % CI: 7.6-9.8) had an adequate LLIN coverage (at least one LLIN for every two people). Out of 13,595 individuals in the surveyed households, 13.6 % (95 % CI: 13.0--4.2) reported having slept under a LLIN the preceding night. Determinants for sleeping under LLIN included living in a household with adequate LLIN coverage [adjusted OR (aOR) = 5.82 (95 % CI: 3.23-10.49)], household heads knowledge about LLINs [aOR = 16.44 (95 % CI: 8.29-32.58)], and female gender [aOR = 1.92 (95 % CI: 1.53-2.40)] (all p-values < 0.001). LLIN use decreased with older age [aOR = 0.29 (95 % CI: 0.21-0.40) for ≥ 15 year-olds, aOR = 0.38 (95 % CI: 0.27-0.55) for 5-14 year-olds] compared to < 5 year-olds (p-value < 0.001). Knowledge on the use of LLIN was good in 37.0 % of the household heads. Repurposed nets were reported serving as fishing nets (30.4 %), fruits and seedlings protection (26.6 %), covering up food (19.0 %) and bed linen (11.5 %).

CONCLUSIONS

Two years after mass distribution, LLIN coverage and use in Lihir Islands is extremely low. Three yearly distribution campaigns may not suffice to maintain an acceptable LLIN coverage unless knowledge on maintenance and use is promoted trough educational campaigns.

Which public health interventions are effective in reducing morbidity, mortality and health inequalities from infectious diseases amongst children in low- and middle-income countries (LMICs): An umbrella review

Despite significant progress in the last few decades, infectious diseases remain a major threat to child health in low- and middle-income countries (LMICs)—particularly amongst more disadvantaged groups. It is imperative to understand the best available evidence concerning which public health interventions reduce morbidity, mortality and health inequalities in children aged under five years. To address this gap, we carried out an umbrella review (a systematic reviews of reviews) to identify evidence on the effects of public health interventions (promotion, protection, prevention) on morbidity, mortality and/or health inequalities due to infectious diseases amongst children in LMICs. Ten databases were searched for records published between 2014–2021 alongside a manual search of gray literature. Articles were quality-assessed using the Assessment of Multiple Systematic Reviews tool (AMSTAR 2). A narrative synthesis was conducted. We identified 60 systematic reviews synthesizing 453 individual primary studies. A majority of the reviews reported on preventive interventions (n = 48), with a minority on promotion (n = 17) and almost no reviews covering health protection interventions (n = 2). Effective interventions for improving child health across the whole population, as well as the most disadvantaged included communication, education and social mobilization for specific preventive services or tools, such as immunization or bed nets. For all other interventions, the effects were either unclear, unknown or detrimental, either at the overall population level or regarding health inequalities. We found few reviews reporting health inequalities information and the quality of the evidence base was generally low. Our umbrella review identified some prevention interventions that might be useful in reducing under five mortality from infectious diseases in LMICs, particularly amongst the most disadvantaged groups.

Ownership and Utilisation of Long-Lasting Insecticidal Nets in Tiko Health District, Southwest Region, Cameroon: A Cross-Sectional Study

INTRODUCTION

Malaria is and remains a serious health concern in Africa. In Cameroon, where malaria is endemic and a major public health problem, the major control measure put in place is the use of long-lasting insecticidal nets (LLINs). In the Tiko Health District (THD), the challenges have been to assess and to evaluate the ownership and utilisation of LLINs. This study sought to assess the ownership and utilisation rates of LLINs in the THD. Methodology. A cross-sectional survey involving 418 households was conducted in four health areas in the THD. A structured questionnaire was used to collect data on LLIN ownership and utilisation as well as sociodemographic characteristics.

RESULTS

The ownership of at least one LLIN per household, coverage, and accessibility were, respectively, 89%, 56.2%, and 66.3%, while installing LLINs on all beds in the household, sleeping under LLINs the previous night (SULPN), and universal utilisation were 72%, 24.9%, and 14.1%, respectively. Factors significantly associated with the ownership of at least one LLIN per household were respondent's age and gender. Heat (21.1%) and forgetfulness (6.5%) were the main reasons postulated for irregular utilisation of LLINs.

CONCLUSION

The ownership LLINs failed to guarantee utilisation and definitely effective control of malaria in the THD, as expected. Continuous and appropriate use of LLINs is indispensable, in addition to periodic sanitation, booster campaigns of LLIN distribution, and evaluation research for effective prevention and control of malaria.

Effect of bed net colour and shape preferences on bed net usage: a secondary data analysis of the 2017 Malawi Malaria Indicator Survey

Background

Malaria remains a significant cause of morbidity and mortality in the paediatric population in Malawi. Insecticide-treated bed nets are a key vector malaria control intervention, however, advancement towards universal access is progressing slowly. Malawi Malaria indicator surveys (MMIS) show diverse user preferences of bed net shape and colour. The objective of this work was to understand if bed net shape and colour preferences affect usage.

Methods

This is a secondary analysis of data from households that participated in the 2016–2017 MMIS. The main outcome variable was net usage defined, at net level, whether someone slept under a particular net on the night before the survey. The main exposure variables were preference attributes, whether a particular net is of a preferred colour or shape as defined by the household respondent. Both bivariate and multivariate logistic regression analyses were done to determine the association between the exposure and outcome variables.

Results

A total of 3729 households with 16,755 individuals were included in this analysis. There were a total 7710 bed nets in households that participated in the survey of which 5435 (70.5%) of these nets had someone sleep under them the previous night before the survey. Bed nets that are of a preferred shape have 3.55 times higher odds of being used than those not preferred [AOR 3.55 (95% CI 2.98, 4.23; p value < 0.001)]. Bed nets that are of a preferred colour have 1.61 times higher odds of being used than those that are not of a preferred colour [AOR 1.61 (95% CI 1.41, 1.84; p value < 0.001].

Conclusions

The results indicate that if a bed net is of a preferred colour or shape, it is more likely to be used. Bed net purchase by malaria stakeholders need to balance more factors on top of preferences such as price and efficacy.

Factors associated with utilization of LLINs among women of child-bearing age in Igabi, Kaduna State, Nigeria

BACKGROUND

The long-lasting insecticidal nets (LLIN) are effective against prevention of malaria and its utilization has been proven to save lives. Despite the mass distribution of LLIN, Nigeria remains the country with the highest malaria burden in Africa. The awareness of LLIN in Nigeria is high, but the utilization is low. The aim of this work is to describe factors associated with the utilization of LLIN among women of child-bearing age (WCBA) in Igabi, Kaduna, Nigeria.

METHODS

A cross-sectional survey was conducted among 630 WCBA selected using a multi-stage sampling at 63 randomly selected villages in Igabi Local Government Area of Kaduna State. Trained female data collectors administered pre-tested structured questionnaires adapted from the Malaria Indicator Survey. Information collected were demographic profile, knowledge of LLIN as a preventive strategy for malaria, and LLIN ownership and utilization. LLIN utilization was assessed by identifying household members that slept under the hanged LLIN the night before the survey. Questions on the awareness of LLIN, ability to define what it is, use of LLIN, what differentiates LLIN from other bed nets, and duration of use before replacement, were scored and categorized as good, average and poor knowledge of LLIN.

RESULTS

A total of 629 WCBA was sampled, their mean age (± SD) was 29.3 (± 6.2) years, 22.0% were pregnant, 40.5% had no formal education, 41.1% were employed, and 47.7% lived in rural communities. Awareness and good knowledge about LLINs for the prevention of malaria was 96.0% and 24.0%, respectively. The proportion of women who slept under a LLIN the night before the survey (utilization) was 70.0% and slightly higher (74.0%) among pregnant WCBA. Women who lived in rural communities were more likely to utilize LLINs compared to their urban counterparts (OR 3.4; 95% CI 2.3-4.9). Younger women (aged < 30 years) were less likely to utilize LLINs compared to the older women (OR 0.7; 95% CI 0.5-0.9).

CONCLUSIONS

The knowledge of LLIN among WCBA was poor, but LLIN utilization was moderate. Living in rural communities and older WCBA were significant characteristics associated with LLIN utilization. Strategies that will improve the utilization of LLIN among the young and urban WCBA should be the focus of the Malaria Elimination Programme (MEP).

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.

PREVALENCE OF MALARIA PARASITAEMIA AND THE USE OF MALARIA PREVENTION MEASURES IN PREGNANT WOMEN IN IBADAN, NIGERIA

BACKGROUND

Malaria complicates up to 58.1% of pregnancies in Nigeria. Preventive measures include intermittent preventive treatment and consistent use of insecticide-treated nets. However, uptake of these interventions can often be sub-optimal.

OBJECTIVE

This study aimed to assess the prevalence of malaria in pregnancy in peri-urban and rural communities of Ibadan, Nigeria and its association with the use of preventive measures.

METHODS

In this cross-sectional study, pregnant women were recruited from selected primary health centres and blood films were taken for malaria parasites. Explanatory variables were the use of bed nets and chemoprophylaxis; the primary outcome was presence of peripheral malaria parasitaemia.

RESULTS

Malaria prevalence was 4.3% (67 of 1570 participants); two-thirds of women with parasitaemia had malaria symptoms. Four hundred and thirty-eight (27.9%) used prescribed sulphadoxine-pyrimethamine prophylaxis, 784 (49.9%) women reported that they consistently slept under insecticide-treated nets, and 236 (15%) complied with both interventions. Bed net use appeared more protective than chemoprophylaxis. However, the protection from malaria in those who used preventive measures was not statistically significant (p=0.075).

CONCLUSION

Malaria prevalence was low. No association was determined between malaria and the use of preventive measures; the lack of association may be due to the low prevalence.

Barriers in distribution, ownership and utilization of insecticide-treated mosquito nets among migrant population in Myanmar, 2016: a mixed methods study

Background

Sleeping under insecticide-treated mosquito nets/long-lasting insecticidal nets (ITNs/LLINs henceforth referred to as ITNs) is one of the core interventions recommended by the World Health Organization to reduce malaria transmission and prevent malaria in high-risk communities, such as migrants, by preventing mosquito bites. The malaria burden among the migrant population is a big challenge for malaria elimination in Myanmar. In this context, this study aimed to assess the ownership and utilization of ITNs and to understand the barriers to distribution and utilization of ITNs among the high-risk migrant communities in the Regional Artemisinin Resistance Initiative (RAI) project areas of Myanmar.

Methods

A sequential mixed methods study (quantitative component: cross-sectional study involving analysis of secondary data available from a survey conducted among migrant households in the RAI project areas of Myanmar in 2016 followed by a descriptive qualitative component in 2018). A total of 17 focus group discussions (involving 121 participants) with different groups of migrants and 17 key-informant interviews with key programme stakeholders were conducted in 4 selected townships of RAI project areas.

Results

Of 3230 migrant households, 63.3% had at least one ITN while 36% had sufficient ITNs (i.e., 1 ITN per 2 persons). Regarding ITN utilization, about 52% of household members reported sleeping under an ITN the previous night, which is similar among under-fives and pregnant women. Over half of all bed nets were ITNs, with nearly one-third having holes or already undergone repairs. The qualitative findings revealed that the key challenges for ITN utilization were insufficient ITNs in households and dislike of ITNs. The barriers to ITN distribution were incomplete migrant mapping due to resource constraints (time, money, manpower) and difficulties in transportation and carrying ITNs.

Conclusion

This study highlights poor ownership and utilization of ITNs among migrants in the RAI project areas of Myanmar and barriers to their ownership and utilization. To achieve universal coverage and utilization, more programmatic support by the programme is needed to carry out complete migrant mapping and continuous ITN distribution in remote locations.

Caregiver exposure to malaria social and behaviour change messages can improve bed net use among children in an endemic country: secondary analysis of the 2015 Nigeria Malaria Indicator Survey

Background

To reduce the malaria burden in Nigeria, the National Malaria Strategic Plan (NMSP) 2014‒2020 calls for the scale-up of prevention and treatment interventions, including social and behaviour change (SBC). SBC interventions can increase awareness and improve the demand for and uptake of malaria interventions. However, there is limited evidence supporting the implementation of SBC interventions to improve key malaria behaviours, such as insecticide-treated bed net (ITN) use, among children in Nigeria.

Methods

Using data from 2015 Nigeria Malaria Indicator Survey, this study used multiple logistic regression to assess the relationship between caregiver exposure to malaria messages and ITN use among children under five.

Results

Caregiver exposure to ITN-related messages was significantly associated with ITN use among children under five (odds ratio [OR] = 1.63, p < 0.001).

Conclusions

The results suggest that caregiver exposure to topic-specific SBC messages improves the use of ITNs among children. Given these results, Nigeria should strive to scale up SBC interventions to help increase ITN use among children in line with the objectives of the NMSP. Further evidence is needed to determine which SBC interventions are the most effective and scalable in Nigeria.

LLIN Evaluation in Uganda Project (LLINEUP): factors associated with ownership and use of long-lasting insecticidal nets in Uganda: a cross-sectional survey of 48 districts

BACKGROUND

Long-lasting insecticidal nets (LLINs) are a key malaria control intervention. To investigate factors associated with ownership and use of LLINs in Uganda, a cross-sectional community survey was conducted in March-June 2017, approximately 3 years after a national Universal Coverage Campaign (UCC).

METHODS

Households from 104 clusters (health sub-districts) in 48 districts were randomly selected using two-staged cluster sampling; 50 households were enrolled per cluster. Outcomes were household ownership of LLINs (at least one LLIN), adequate LLIN coverage (at least one LLIN per 2 residents), and use of LLINs (resident slept under a LLIN the previous night). Associations between variables of interest and outcomes were made using multivariate logistic regression.

RESULTS

In total, 5196 households, with 29,627 residents and 6980 bed-nets, were included in the analysis. Overall, 65.0% of households owned at least one LLIN (down from 94% in 2014). In the adjusted analysis, factors most strongly associated with LLIN ownership were living in a wealthier household (highest tercile vs lowest; adjusted odds ratio [aOR] 1.94, 95% CI 1.66-2.28, p < 0.001) and time since the last UCC (29-37 vs 42-53 months; aOR 1.91, 95% CI 1.60-2.28, p < 0.001). Only 17.9% of households had adequate LLIN coverage (down from 65% in 2014). Factors most strongly associated with adequate coverage were fewer residents (2-4 vs ≥ 7; aOR 6.52, 95% CI 5.13-8.29, p < 0.001), living in a wealthier household (highest tercile vs lowest; aOR: 2,32, 95% CI 1.88-2.85, p < 0.001) and time since the last UCC (29-37 vs 42-53 months; aOR 2.13, 95% CI 1.61-2.81, p < 0.001). Only 39.5% of residents used a LLIN the previous night. Age was strongly associated with LLIN use, as were household wealth and time since the last UCC. Children < 5 years (44.7%) and residents > 15 years (44.1%) were more likely to use nets than children aged 5-15 years (30.7%; < 5 years: aOR 1.71, 95% CI 1.62-1.81, p < 0.001; > 15 years: aOR 1.37, 95% CI 1.29-1.45, p < 0.001).

CONCLUSIONS

Long-lasting insecticidal net ownership and coverage have reduced markedly in Uganda since the last net distribution campaign in 2013/14. Houses with many residents, poorer households, and school-aged children should be targeted to improve LLIN coverage and use. Trial registration This study is registered with ISRCTN (17516395).

Effect of individual and community-level bed net usage on malaria prevalence among under-fives in the Democratic Republic of Congo

Background

Understanding the contribution of community-level long-lasting, insecticidal net (LLIN) coverage to malaria control is critical to planning and assessing intervention campaigns. The Democratic Republic of Congo (DRC), which has one of the highest burdens of malaria cases and deaths and has dramatically scaled up LLIN ownership in recent years thus it is an ideal setting to evaluate the effect of individual versus community-level use to prevent malaria among children under the age of 5.

Results

Data were derived from the 2013–2014 DRC Demographic and Health Survey. Community-level LLIN usage was significantly associated with protection against malaria, even when individual-level LLIN usage was included in the model. In stratified analysis, higher levels of community LLIN coverage enhanced the protective effect of individual LLIN usage, resulting in lower malaria prevalence among individuals who used a LLIN. A sub-analysis of individual LLIN usage by insecticide type revealed deltamethrin-treated nets were more protective than permethrin-treated nets, suggesting that mosquitoes in the DRC are more susceptible to deltamethrin.

Conclusions

This study examines the effects of individual and community-level LLIN usage in young children in an area of high ITN usage. Individual and community LLIN usage were significantly associated with protection against malaria in children under 5 in the DRC. Importantly, the protective effect of individual LLIN usage against malaria is enhanced when community LLIN coverage is higher, demonstrating the importance of increasing community-level LLIN usage. LLINs treated with deltamethrin were shown to be more protective against malaria than LLINs treated with permethrin. Demographic and Health Surveys are thus a novel and important means of surveillance for insecticide resistance.

Use of programme theory to understand the differential effects of interventions across socio-economic groups in systematic reviews-a systematic methodology review

BACKGROUND

Systematic review guidance recommends the use of programme theory to inform considerations of if and how healthcare interventions may work differently across socio-economic status (SES) groups. This study aimed to address the lack of detail on how reviewers operationalise this in practice.

METHODS

A methodological systematic review was undertaken to assess if, how and the extent to which systematic reviewers operationalise the guidance on the use of programme theory in considerations of socio-economic inequalities in health. Multiple databases were searched from January 2013 to May 2016. Studies were included if they were systematic reviews assessing the effectiveness of an intervention and included data on SES. Two reviewers independently screened all studies, undertook quality assessment and extracted data. A narrative approach to synthesis was adopted.

RESULTS

A total of 37 systematic reviews were included, 10 of which were explicit in the use of terminology for 'programme theory'. Twenty-nine studies used programme theory to inform both their a priori assumptions and explain their review findings. Of these, 22 incorporated considerations of both what and how interventions do/do not work in SES groups to both predict and explain their review findings. Thirteen studies acknowledged 24 unique theoretical references to support their assumptions of what or how interventions may have different effects in SES groups. Most reviewers used supplementary evidence to support their considerations of differential effectiveness. The majority of authors outlined a programme theory in the "Introduction" and "Discussion" sections of the review to inform their assumptions or provide explanations of what or how interventions may result in differential effects within or across SES groups. About a third of reviews used programme theory to inform the review analysis and/or synthesis. Few authors used programme theory to inform their inclusion criteria, data extraction or quality assessment. Twenty-one studies tested their a priori programme theory.

CONCLUSIONS

The use of programme theory to inform considerations of if, what and how interventions lead to differential effects on health in different SES groups in the systematic review process is not yet widely adopted, is used implicitly, is often fragmented and is not implemented in a systematic way.

Knowledge, access and utilization of bed-nets among stable and seasonal migrants in an artemisinin resistance containment area of Myanmar

Background

Myanmar lies in the Greater Mekong sub-region of South-East Asia faced with the challenge of emerging resistance to artemisinin combination therapies (ACT). Migrant populations are more likely than others to spread ACT resistance. A vital intervention to reduce malaria transmission, resistance spread and eliminate malaria is the use of bed nets. Among seasonal and stable migrants in an artemisinin resistance containment region of Myanmar, we compared a) their household characteristics, b) contact with health workers and information material, and c) household knowledge, access and utilization of bed nets.

Methods

Secondary data from community-based surveys on 2484 migrant workers (2013 and 2014, Bago Region) were analyzed of which 37% were seasonal migrants. Bed net access and utilization were assessed using a) availability of at least one bed net per household, and b) one bed net per two persons, and c) proportion of household members who slept under abed net during the previous night (Indicator targets = 100%).

Results

Over 70% of all migrants were from unstable work settings with short transitory stays. Average household size was five (range 1–25) and almost half of all households had children under-five years. Roughly 10 % of migrants were night-time workers.

Less than 40% of households had contact with health workers and less than 30% had exposure to information education and communication (IEC) materials, the latter being significantly lower among seasonal migrants. About 70% of households were aware of the importance of insecticide-treated bed-nets/long-lasting insecticidal nets (ITNs/LLINs), but knowledge on insecticide impregnation and retreatment of ITNs was poor (< 10%).

Although over 95% of households had access to at least one bed net, the number with one bed net per two persons was grossly inadequate (13% for stable migrants and 9% for seasonal migrants, P = 0.001). About half of all household members slept under a bed net during the previous night.

Conclusions

This study reveals important short-falls in knowledge, access and utilization of bed nets among migrants in Myanmar. Possible ways forward include frequent distribution campaigns to compensate for short transitory stays, matching household distributions to household size, enhanced information campaigns and introducing legislation to make mosquito repellents available for night-time workers at plantations and farms. Better understanding through qualitative research is also merited.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-017-0353-8) contains supplementary material, which is available to authorized users.

Delivery arrangements for health systems in low-income countries: an overview of systematic reviews

BACKGROUND

Delivery arrangements include changes in who receives care and when, who provides care, the working conditions of those who provide care, coordination of care amongst different providers, where care is provided, the use of information and communication technology to deliver care, and quality and safety systems. How services are delivered can have impacts on the effectiveness, efficiency and equity of health systems. This broad overview of the findings of systematic reviews can help policymakers and other stakeholders identify strategies for addressing problems and improve the delivery of services.

OBJECTIVES

To provide an overview of the available evidence from up-to-date systematic reviews about the effects of delivery arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on delivery arrangements and informing refinements of the framework for delivery arrangements outlined in the review.

METHODS

We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of delivery arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use, healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty or employment) and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the findings. Two overview authors independently screened reviews, extracted data, and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence), and assessments of the relevance of findings to low-income countries.

MAIN RESULTS

We identified 7272 systematic reviews and included 51 of them in this overview. We judged 6 of the 51 reviews to have important methodological limitations and the other 45 to have only minor limitations. We grouped delivery arrangements into eight categories. Some reviews provided more than one comparison and were in more than one category. Across these categories, the following intervention were effective; that is, they have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects. Who receives care and when: queuing strategies and antenatal care to groups of mothers. Who provides care: lay health workers for caring for people with hypertension, lay health workers to deliver care for mothers and children or infectious diseases, lay health workers to deliver community-based neonatal care packages, midlevel health professionals for abortion care, social support to pregnant women at risk, midwife-led care for childbearing women, non-specialist providers in mental health and neurology, and physician-nurse substitution. Coordination of care: hospital clinical pathways, case management for people living with HIV and AIDS, interactive communication between primary care doctors and specialists, hospital discharge planning, adding a service to an existing service and integrating delivery models, referral from primary to secondary care, physician-led versus nurse-led triage in emergency departments, and team midwifery. Where care is provided: high-volume institutions, home-based care (with or without multidisciplinary team) for people living with HIV and AIDS, home-based management of malaria, home care for children with acute physical conditions, community-based interventions for childhood diarrhoea and pneumonia, out-of-facility HIV and reproductive health services for youth, and decentralised HIV care. Information and communication technology: mobile phone messaging for patients with long-term illnesses, mobile phone messaging reminders for attendance at healthcare appointments, mobile phone messaging to promote adherence to antiretroviral therapy, women carrying their own case notes in pregnancy, interventions to improve childhood vaccination. Quality and safety systems: decision support with clinical information systems for people living with HIV/AIDS. Complex interventions (cutting across delivery categories and other health system arrangements): emergency obstetric referral interventions.

AUTHORS' CONCLUSIONS

A wide range of strategies have been evaluated for improving delivery arrangements in low-income countries, using sound systematic review methods in both Cochrane and non-Cochrane reviews. These reviews have assessed a range of outcomes. Most of the available evidence focuses on who provides care, where care is provided and coordination of care. For all the main categories of delivery arrangements, we identified gaps in primary research related to uncertainty about the applicability of the evidence to low-income countries, low- or very low-certainty evidence or a lack of studies.

Implementation strategies for health systems in low-income countries: an overview of systematic reviews

BACKGROUND

A key function of health systems is implementing interventions to improve health, but coverage of essential health interventions remains low in low-income countries. Implementing interventions can be challenging, particularly if it entails complex changes in clinical routines; in collaborative patterns among different healthcare providers and disciplines; in the behaviour of providers, patients or other stakeholders; or in the organisation of care. Decision-makers may use a range of strategies to implement health interventions, and these choices should be based on evidence of the strategies' effectiveness.

OBJECTIVES

To provide an overview of the available evidence from up-to-date systematic reviews about the effects of implementation strategies for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on alternative implementation strategies and informing refinements of the framework for implementation strategies presented in the overview.

METHODS

We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of implementation strategies on professional practice and patient outcomes and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the review findings. Two overview authors independently screened reviews, extracted data and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence) and assessments of the relevance of findings to low-income countries.

MAIN RESULTS

We identified 7272 systematic reviews and included 39 of them in this overview. An additional four reviews provided supplementary information. Of the 39 reviews, 32 had only minor limitations and 7 had important methodological limitations. Most studies in the reviews were from high-income countries. There were no studies from low-income countries in eight reviews.Implementation strategies addressed in the reviews were grouped into four categories - strategies targeting:1. healthcare organisations (e.g. strategies to change organisational culture; 1 review);2. healthcare workers by type of intervention (e.g. printed educational materials; 14 reviews);3. healthcare workers to address a specific problem (e.g. unnecessary antibiotic prescription; 9 reviews);4. healthcare recipients (e.g. medication adherence; 15 reviews).Overall, we found the following interventions to have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects.1.Strategies targeted at healthcare workers: educational meetings, nutrition training of health workers, educational outreach, practice facilitation, local opinion leaders, audit and feedback, and tailored interventions.2.Strategies targeted at healthcare workers for specific types of problems: training healthcare workers to be more patient-centred in clinical consultations, use of birth kits, strategies such as clinician education and patient education to reduce antibiotic prescribing in ambulatory care settings, and in-service neonatal emergency care training.3. Strategies targeted at healthcare recipients: mass media interventions to increase uptake of HIV testing; intensive self-management and adherence, intensive disease management programmes to improve health literacy; behavioural interventions and mobile phone text messages for adherence to antiretroviral therapy; a one time incentive to start or continue tuberculosis prophylaxis; default reminders for patients being treated for active tuberculosis; use of sectioned polythene bags for adherence to malaria medication; community-based health education, and reminders and recall strategies to increase vaccination uptake; interventions to increase uptake of cervical screening (invitations, education, counselling, access to health promotion nurse and intensive recruitment); health insurance information and application support.

AUTHORS' CONCLUSIONS

Reliable systematic reviews have evaluated a wide range of strategies for implementing evidence-based interventions in low-income countries. Most of the available evidence is focused on strategies targeted at healthcare workers and healthcare recipients and relates to process-based outcomes. Evidence of the effects of strategies targeting healthcare organisations is scarce.

The Economic Value of Long-Lasting Insecticidal Nets and Indoor Residual Spraying Implementation in Mozambique

Malaria-endemic countries have to decide how much of their limited resources for vector control to allocate toward implementing long-lasting insecticidal nets (LLINs) versus indoor residual spraying (IRS). To help the Mozambique Ministry of Health use an evidence-based approach to determine funding allocation toward various malaria control strategies, the Global Fund convened the Mozambique Modeling Working Group which then used JANUS, a software platform that includes integrated computational economic, operational, and clinical outcome models that can link with different transmission models (in this case, OpenMalaria) to determine the economic value of vector control strategies. Any increase in LLINs (from 80% baseline coverage) or IRS (from 80% baseline coverage) would be cost-effective (incremental cost-effectiveness ratios ≤ $114/disability-adjusted life year averted). However, LLIN coverage increases tend to be more cost-effective than similar IRS coverage increases, except where both pyrethroid resistance is high and LLIN usage is low. In high-transmission northern regions, increasing LLIN coverage would be more cost-effective than increasing IRS coverage. In medium-transmission central regions, changing from LLINs to IRS would be more costly and less effective. In low-transmission southern regions, LLINs were more costly and less effective than IRS, due to low LLIN usage. In regions where LLINs are more cost-effective than IRS, it is worth considering prioritizing LLIN coverage and use. However, IRS may have an important role in insecticide resistance management and epidemic control. Malaria intervention campaigns are not a one-size-fits-all solution, and tailored approaches are necessary to account for the heterogeneity of malaria epidemiology.

Delivering insecticide-treated nets for malaria prevention: innovative strategies

The wide-scale adoption of insecticide-treated nets (ITNs) has led to significant reductions in malaria morbidity and mortality worldwide. Delivery of ITNs to the 3.2 billion people at risk of malaria requires multiple steps in diverse settings. The effectiveness of the delivery of ITNs in order to prevent malaria relies on activities that include ITN manufacturing and design, integration into national and international malaria prevention policies, supplying and distributing ITNs to households and individuals, and, finally, programs focused on spurring demand for and use of ITNs by individuals at risk. This paper reviews some recent innovative strategies for ITN delivery across these four domains, places these innovations within the context of the history of ITN deployment, and identifies opportunities to further improve the effectiveness of this ubiquitous public health tool.

The use of mosquito repellents at three sites in India with declining malaria transmission: surveys in the community and clinic

Background

Repellents such as coils, vaporizers, mats and creams can be used to reduce the risk of malaria and other infectious diseases. Although evidence for their effectiveness is limited, they are advertised as providing an additional approach to mosquito control in combination with other strategies, e.g. insecticide-treated nets. We examined the use of repellents in India in an urban setting in Chennai (mainly Plasmodium vivax malaria), a peri-urban setting in Nadiad (both P. vivax and P. falciparum malaria), and a more rural setting in Raurkela (mainly P. falciparum malaria).

Methods

The use of repellents was examined at the household level during a census, and at the individual level in cross-sectional surveys and among patients visiting a clinic with fever or other symptoms. Factors associated with their use were examined in a multivariate analysis, and the association between malaria and the use of repellents was assessed among survey- and clinic participants.

Results

Characteristics of participants differed by region, with more people of higher education present in Chennai. Use of repellents varied between 56–77 % at the household level and between 32–78 % at the individual level. Vaporizers were the main repellents used in Chennai, whereas coils were more common in Nadiad and Raurkela. In Chennai and Nadiad, vaporizers were more likely to be used in households with young male children. Vaporizer use was associated with higher socio-economic status (SES) in households in Chennai and Nadiad, whereas use of coils was greater in the lower SES strata. In Raurkela, there was a higher use of coils among the higher SES strata. Education was associated with the use of a repellent among survey participants in Chennai and clinic study participants in Chennai and Nadiad. Repellent use was associated with less malaria in the clinic study in Chennai and Raurkela, but not in the surveys, with the exception of the use of coils in Nadiad.

Conclusions

Repellents are widely used in India. Their use is influenced by the level of education and SES. Information on effectiveness and guidance on choices may improve rational use.

Electronic supplementary material

The online version of this article (doi:10.1186/s13071-016-1709-9) contains supplementary material, which is available to authorized users.

Comparing ownership and use of bed nets at two sites with differential malaria transmission in western Kenya

Background

Challenges persist in ensuring access to and optimal use of long-lasting, insecticidal bed nets (LLINs). Factors associated with ownership and use may differ depending on the history of malaria and prevention control efforts in a specific region. Understanding how the cultural and social-environmental context of bed net use may differ between high- and low-risk regions is important when identifying solutions to improve uptake and appropriate use.

Methods

Community forums and a household, cross-sectional survey were used to collect information on factors related to bed net ownership and use in western Kenya. Sites with disparate levels of transmission were selected, including an endemic lowland area, Miwani, and a highland epidemic-prone area, Kapkangani. Analysis of ownership was stratified by site. A combined site analysis was conducted to examine factors associated with use of all available bed nets. Logistic regression modelling was used to determine factors associated with ownership and use of owned bed nets.

Results

Access to bed nets as the leading barrier to their use was identified in community forums and cross-sectional surveys. While disuse of available bed nets was discussed in the forums, it was a relatively rare occurrence in both sites. Factors associated with ownership varied by site. Education, perceived risk of malaria and knowledge of individuals who had died of malaria were associated with higher bed net ownership in the highlands, while in the lowlands individuals reporting it was easy to get a bed net were more likely to own one. A combined site analysis indicated that not using an available bed net was associated with the attitudes that taking malaria drugs is easier than using a bed net and that use of a bed net will not prevent malaria. In addition, individuals with an unused bed net in the household were more likely to indicate that bed nets are difficult to use, that purchased bed nets are better than freely distributed ones, and that bed nets should only be used during the rainy season.

Conclusion

Variations in factors associated with ownership should be acknowledged when constructing messaging and distribution campaigns. Despite reports of bed nets being used for other purposes, those in the home were rarely unused in these communities. Disuse seemed to be related to beliefs that can be addressed through education programmes. As mass distributions continue to take place, additional research is needed to determine if factors associated with LLIN ownership and use change with increasing availability of LLIN.

Community point distribution of insecticide-treated bed nets and community health worker hang-up visits in rural Zambia: a decision-focused evaluation

Background

In 2013, the Zambian Ministry of Health through its National Malaria Control Programme distributed over two million insecticide-treated bed nets (ITNs) in four provinces using a door-to-door distribution strategy, and more than 6 million ITNs were allocated to be distributed in 2014. This study was commissioned to measure attendance rates at a community point distribution and to examine the impact of follow-up community health worker (CHW) hang-up visits on short and medium-term ITN retention and usage with a view of informing optimal ITN distribution strategy in Zambia.

Methods

Households received ITNs at community point distributions conducted in three rural communities in Rufunsa District, Zambia. Households were then randomly allocated into five groups to receive CHW visits to hang any unhung ITNs at different intervals: 1–3, 5–7, 10–12, 15–17 days, and no hang-up visit. Follow-up surveys were conducted among all households at 7–11 weeks after distribution and at 5–6 months after distribution to measure short- and medium-term household retention and usage of ITNs.

Results

Of the 560 pre-registered households, 540 (96.4 %) attended the community point distribution. Self-installation of ITNs by households increased over the first 10 days after the community point distribution. Retention levels remained high over time with 90.2 % of distributed ITNs still in the household at 7–11 weeks and 85.7 % at 5–6 months. Retention did not differ between households that received a CHW visit and those that did not. At 7–11 weeks, households had an average of 73.8 % of sleeping spaces covered compared to 80.3 % at 5–6 months. On average, 65.6 % of distributed ITNs were hanging at 7–11 weeks compared to 63.1 % at 5–6 months. While a CHW hang-up visit was associated with increased usage at 7–11 weeks, this difference was no longer apparent at 5–6 months.

Conclusions

This evaluation revealed that (1) the community point distributions achieved high attendance rates followed by acceptable rates of short-term and medium-term ITN retention and usage, as compared to reported rates achieved by door-to-door distributions in the recent past, (2) CHW hang-up visits had a modest short-term impact on ITN usage but no medium-term effect, and (3) community point distributions can yield sizeable time savings compared to door-to-door distributions.

Spatially aggregated clusters and scattered smaller loci of elevated malaria vector density and human infection prevalence in urban Dar es Salaam, Tanzania

Background

Malaria transmission, primarily mediated by Anopheles gambiae, persists in Dar es Salaam (DSM) despite high coverage with bed nets, mosquito-proofed housing and larviciding. New or improved vector control strategies are required to eliminate malaria from DSM, but these will only succeed if they are delivered to the minority of locations where residual transmission actually persists. Hotspots of spatially clustered locations with elevated malaria infection prevalence or vector densities were, therefore, mapped across the city in an attempt to provide a basis for targeting supplementary interventions.

Methods

Two phases of a city-wide population-weighted random sample of cross-sectional household surveys of malaria infections were complemented by two matching phases of geographically overlapping, high-resolution, longitudinal vector density surveys; spanning 2010–2013. Spatial autocorrelations were explored using Moran’s I and hotspots were detected using flexible spatial scan statistics.

Results

Seven hotspots of spatially clustered elevated vector density and eight of malaria infection prevalence were detected over both phases. Only a third of vectors were collected in hotspots in phase 1 (30 %) and phase 2 (33 %). Malaria prevalence hotspots accounted for only half of malaria infections detected in phase 1 (55 %) and phase 2 (47 %). Three quarters (76 % in phase 1 and 74 % in phase 2) of survey locations with detectable vector populations were outside of hotspots. Similarly, more than half of locations with higher infection prevalence (>10 %) occurred outside of hotspots (51 % in phase 1 and 54 % in phase 2). Vector proliferation hazard (exposure to An. gambiae) and malaria infection risk were only very loosely associated with each other (Odds ratio (OR) [95 % Confidence Interval (CI)] = 1.56 [0.89, 1.78], P = 0.52)).

Conclusion

Many small, scattered loci of local malaria transmission were haphazardly scattered across the city, so interventions targeting only currently identifiable spatially aggregated hotspots will have limited impact. Routine, spatially comprehensive, longitudinal entomological and parasitological surveillance systems, with sufficient sensitivity and spatial resolution to detect these scattered loci, are required to eliminate transmission from this typical African city. Intervention packages targeted to both loci and hotspots of transmission will need to suppress local vector proliferation, treat infected residents and provide vulnerable residents with supplementary protective measures against exposure.

Health equity: evidence synthesis and knowledge translation methods

BACKGROUND

At the Rio Summit in 2011 on Social Determinants of Health, the global community recognized a pressing need to take action on reducing health inequities. This requires an improved evidence base on the effects of national and international policies on health inequities. Although systematic reviews are recognized as an important source for evidence-informed policy, they have been criticized for failing to assess effects on health equity.

METHODS

This article summarizes guidance on both conducting systematic reviews with a focus on health equity and on methods to translate their findings to different audiences. This guidance was developed based on a series of methodology meetings, previous guidance, a recently developed reporting guideline for equity-focused systematic reviews (PRISMA-Equity 2012) and a systematic review of methods to assess health equity in systematic reviews.

RESULTS

We make ten recommendations for conducting equity-focused systematic reviews; and five considerations for knowledge translation. Illustrative examples of equity-focused reviews are provided where these methods have been used.

CONCLUSIONS

Implementation of the recommendations in this article is one step toward monitoring the impact of national and international policies and programs on health equity, as recommended by the 2011 World Conference on Social Determinants of Health.