Free distribution of insecticide treated bed nets to pregnant women in Kinshasa: an effective way to achieve 80% use by women and their newborns

Level of awareness and utilization of insecticide-treated bed nets among medical students as measures for reducing malaria episodes

This study examined the level of awareness and utilization of insecticide-treated bed nets among medical students as measures for reducing malaria episodes in Delta State University, Abraka. It was a descriptive study with objectives and research questions formulated to achieve the study design. A sample size of 200 male and female students resident in the campus hostels were selected using random sampling technique. A self-structured questionnaire was designed and administered to the study participants, however, only 148 copies of the questionnaires were successfully retrieved and used for the study. Data generated were subjected to quantitative statistical analysis for frequencies, percentages, average mean and Chi-square testing. Findings revealed that the level of awareness was significantly associated with the role of health workers in the distribution of insecticide-treated bed nets in Delta State University, Abraka, although, factors hindering health workers from distributing insecticide-treated bed nets were identified. There was significant difference between perception of medical students and the utilization of insecticide-treated bed nets on risk of malaria spread. In addition, there was significant difference between the benefits of using insecticide-treated bed nets and the prevention and control of malaria. We therefore conclude that regular utilization of insecticide-treated bed nets due to adequate awareness eliminates contact with mosquitoes and prevents transmitting vectors of malaria from having contact with the users of insecticide-treated bed net. Massive health education campaign is recommended to further scale up the awareness and effective utilization of insecticide-treated bed nets towards prevention and control of malaria bites among students in Delta State University, Abraka.

The oral repellent - science fiction or common sense? Insects, vector-borne diseases, failing strategies, and a bold proposition

Over the last decades, unimaginable amounts of money have gone into research and development of vector control measures, repellents, treatment, and vaccines for vector borne diseases. Technological progress and scientific breakthroughs allowed for ever more sophisticated and futuristic strategies. Yet, each year, millions of people still die or suffer from potentially serious consequences of malaria or dengue to more recent infections, such as zika or chikungunya, or of debilitating consequences of neglected tropical diseases. This does not seem value for money. In addition, all current vector control strategies and personal protection methods have shortcomings, some serious, that are either destructive to non-target species or unsatisfactory in their effectiveness. On the other hand, the rapid decline in insect populations and their predators reflects decades-long aggressive and indiscriminate vector control. This major disruption of biodiversity has an impact on human life not anticipated by the well-meaning killing of invertebrates. The objective of this paper is to re-examine current control methods, their effectiveness, their impact on biodiversity, human and animal health, and to call for scientific courage in the pursuit of fresh ideas. This paper brings together topics that are usually presented in isolation, thereby missing important links that offer potential solutions to long-standing problems in global health. First, it serves as a reminder of the importance of insects to human life and discusses the few that play a role in transmitting disease. Next, it examines critically the many currently employed vector control strategies and personal protection methods. Finally, based on new insights into insect chemo-sensation and attractants, this perspective makes a case for revisiting a previously abandoned idea, the oral repellent, and its use via currently successful methods of mass-application. The call is out for focused research to provide a powerful tool for public health, tropical medicine, and travel medicine.

Caregivers' use of insecticide-treated nets is associated with the use of ITNs by children under the age of five in Ghana

BACKGROUND

Malaria poses a greater risk to children under the age of five years due to its high morbidity and mortality rates. The use of Insecticide-Treated Net (ITN) has been proven to be an effective preventive intervention in the control of malaria. However, its utilisation remains low. This study assessed the association of mother or caregiver's utilisation of ITN on its use by their children under five years of age in Ghana.

METHODS

This study used data from the 2019 Ghana Malaria Indicator Survey (GMIS). The study analysed a weighted sample of 1,876 women aged 15-49 years who had at least one child under the age of five. In this study, the outcome variable is mosquito bed net use in children under five years. We performed descriptive statistics, chi-square tests, and multinomial logistic regressions.

RESULTS

Of the women studied, 58.59% [95% CI: 55.39, 61.71] slept under mosquito bed nets the previous night. The utilisation of ITN in children under five was 61.88% [95% CI: 58.43, 65.2] on the night before the study. The adjusted logistic regression revealed that mothers/caregivers who slept under a mosquito bed net were more likely to have their children under five years of age sleeping under a mosquito bed net (RRR = 2.47, 95% CI: 1.48, 4.12; p <0.001). In addition, the use of ITN in children under five was also found to be predicted by the number of ANC visits, the number of children under five in the household, and wealth status.

CONCLUSION

The study found that the use of ITN by mothers/caregivers and their children remains low in Ghana. Nevertheless, we found that when a mother uses ITN, her children under the age of five are more likely to use it as well.

Multilevel Modelling of Individual, Community and Regional Level Factors Associated with Insecticide-Treated Net Usage among Pregnant Women in Ethiopia

Background: Pregnant women who are infected with malaria usually have more severe symptoms and negative health outcomes than women who are not pregnant, with higher rates of miscarriage, intrauterine demise, premature delivery, low-birth-weight neonates, and neonatal death. Based on evidence from the 2016 Ethiopia Demographic and Health Survey, this study assessed the variation in insecticide-treated nets (ITNs) usage and its associated factors among pregnant women in Ethiopia. Methods: Data from a total of 1122 women who were pregnant at the time of the survey were included in the final analysis. Bivariate and multilevel analyses were conducted. Multilevel modeling with fixed and random coefficients was used to estimate the variation in pregnant women’s ITNs usage across communities (residence areas) and regions of Ethiopia. Results: Out of the total 1122 pregnant women, 58.37% slept under a net and 41.63% did not sleep under nets. Significant variations were observed in pregnant women’s ITNs usage across communities (residence areas) and regions of Ethiopia, with between variations in pregnant women’s ITNs usage across communities (residence areas) and regions. In addition, the region, place of residence, wealth index, educational level, and age of the women as well as whether they believed that mosquito bites cause malaria were significant factors in pregnant women’s usage of ITNs. Pregnant women in Ethiopia had moderate usage of ITNs with varied risk factors at the individual, community, and regional levels. Conclusion: Based on the factors identified, there is a need to implement and/or strengthen programs (e.g., regular sensitization) that intensify high coverage of ITNs for effective malaria prevention in Ethiopia, especially among pregnant women who do not use ITNs.

Long lasting insecticidal mosquito nets (LLINs) ownership, use and coverage following mass distribution campaign in Lake Victoria basin, Western Kenya

Background

Long-lasting insecticidal nets (LLINs) are the most widely used malaria prevention and control intervention in Africa. However, their effectiveness may vary depending on their local geographic coverage, ownership and use at household level. This study aimed at assessing LLINs ownership and use following mass distribution campaign in western Kenya.

Methods

A cross-sectional study was conducted in November 2017. A total of 160 households were randomly selected from 16 villages. Structured questionnaires were used to collect data on households’ knowledge on malaria, LLINs ownership, utilization and their perceived benefits. Data was analyzed using IBM Statistical Package for Social Sciences (SPSS) version 21 for windows. Variables were presented as proportions and associations between variables tested using Pearson’s chi-square test.

Results

Malaria was reported to be the most frequently occurring disease (87.5%) in the area. Children under 5 years of age were reported to be at higher risks of malaria infection (28.6%). Around 31% of the respondents reported to have at least one member of the household sick with malaria a week before the interview. Commonly cited signs and symptoms of malaria were; fever (24.1%), headache (17.7%), vomiting (14.5%) feeling cold (12.6%) and loss of appetite (10%). There were 382 reported LLINs among 753 occupants in the 160 households surveyed. The average LLIN ownership was 2.4 nets per household and 1.97 persons per LLIN. Among the surveyed households, 96.9% owned at least one LLIN and 64.1% owned at least one LLIN for every two people. Among those who owned LLINs, 98.1% reported using them the previous night. Ownership per household ranged from 0 to 6 with a mean of 2.39. More than three quarter of the nets were acquired through free mass distribution campaigns and 80% were acquired less than 6 months prior to the survey.

Conclusion

Despite high net coverage and use, a number of households experienced malaria episodes in the study area. There is need to investigate the likelihood of outdoor malaria transmission and assess the physical integrity of the existing LLINs and their insecticidal effectiveness in protecting household members against malaria.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11062-7.

Men's Response to Obulamu Campaign Messages about Male Involvement in Maternal Health: Mukono District, Uganda

Men's involvement makes a difference in maternal health. Well-informed and supportive men may encourage their wives to get more complete and regular antenatal care. In much of sub-Saharan Africa, however, men's involvement with their wives' health during pregnancy is minimal. This study investigated men's response to Obulamu: How's Your Pregnancy radio campaign messages about attending antenatal care with their wives, delivering at a health facility, being tested for HIV, maintaining maternal nutrition, and using malaria prevention. We conducted eight focus group discussions ranging from six to ten participants each: two groups of men from a rural area, two groups of men from a peri-urban area, and two groups each of expectant or recent mothers from the same rural and peri-urban areas. We also conducted six key informant interviews of midwives and other healthcare providers. Findings revealed that participants were highly exposed to the Obulamu campaign and knowledgeable about campaign messages. Most men expressed positive attitudes toward behaviors promoted by the campaign and voiced an intention to change their behaviors. Key informant interviews confirmed that since the start of the campaign an increase in male involvement with maternity visits had taken place. However, a sizeable minority of men, mostly rural residents, resisted involvement in their wives' antenatal visits because of poverty, gender and cultural stereotypes, fear of HIV testing, and incongruity between messages and the realities of antenatal clinical practice. An interaction between individual and institutional-level factors as posited by the social ecological model was clearly evident; there was an incongruity between encouraging Obulamu messages about men's involvement and the discouraging realities of antenatal clinical practice.

Can ITN distribution policies increase children's ITN use? A DHS analysis

Background

Insecticide-treated nets (ITN) have largely been distributed via mass distribution campaigns. Since 2011, however, the World Health Organization (WHO) has recommended additional ITN distribution via routine antenatal care (ANC) and expanded programme on immunization (EPI) services. Countries have begun to implement these routine facility-based distribution strategies, but inconsistently, and there is little research on outcomes of these new programmes. This paper investigates the impact of ITN distribution policies on children’s net use, comparing countries with different policies in place.

Methods

Demographic Health Surveys from 25 countries in Africa were used to analyse household ITN ownership, and ITN use among children under 5 years of age. Countries were categorized in terms of the ITN facility-based distribution policies in place, based on nationally reported policies and distribution data provided to the WHO. The analysis was conducted for individual countries and then pooled with all countries in each category weighted equally to present the average country experience, by ITN distribution policy.

Results

Household ITN ownership, children’s ITN use, and children’s ITN use in households with at least one ITN increase with each additional routine facility-based distribution policy. An average of 54.0% of children slept under an ITN in countries with ITN distribution via ANC and EPI, compared to 34.3% and 24.7% in countries with ITN distribution via ANC only, or no facility-based distribution, respectively. Linear regression found a 13% increase in net use among children under 5, on average, with each additional ITN distribution policy.

Conclusion

ITN distribution via ANC and EPI can not only assist countries in maintaining ITN ownership and use, but may be extremely effective at increasing ITN ownership and use. There is also an additional benefit associated with combined ANC and EPI-based ITN distribution, compared to ANC distribution alone.

The relative roles of ANC and EPI in the continuous distribution of LLINs: a qualitative study in four countries

Background

The continuous distribution of long-lasting insecticidal nets (LLINs) for malaria prevention, through the antenatal care (ANC) and the Expanded Programme on Immunizations (EPI), is recommended by the WHO to improve and maintain LLIN coverage. Despite these recommendations, little is known about the relative strengths and weaknesses of the ANC and EPI-based LLIN distribution. This study aimed to explore and compare the roles of the ANC and EPI for LLIN distribution in four African countries.

Methods

In a qualitative evaluation of continuous distribution through the ANC and EPI, semi-structured, individual and group interviews were conducted in Kenya, Malawi, Mali, and Rwanda. Respondents included national, sub-national, and facility-level health staff, and were selected to capture a range of roles related to malaria, ANC and EPI programmes. Policies, guidelines, and data collection tools were reviewed as a means of triangulation to assess the structure of LLIN distribution, and the methods of data collection and reporting for malaria, ANC and EPI programmes.

Results

In the four countries visited, distribution of LLINs was more effectively integrated through ANC than through EPI because of a) stronger linkages and involvement between malaria and reproductive health programmes, as compared to malaria and EPI, and b) more complete programme monitoring for ANC-based distribution, compared to EPI-based distribution.

Conclusions

Opportunities for improving the distribution of LLINs through these channels exist, especially in the case of EPI. For both ANC and EPI, integrated distribution of LLINs has the potential to act as an incentive, improving the already strong coverage of both these essential services. The collection and reporting of data on LLINs distributed through the ANC and EPI can provide insight into the performance of LLIN distribution within these programmes. Greater attention to data collection and use, by both the global malaria community, and the integrated programmes, can improve this distribution channel strength and effectiveness.

Use of Insecticide-Treated Mosquito Net among Pregnant Women and Guardians of Children under Five in the Democratic Republic of the Congo

Background

Insecticide-treated mosquito nets (ITNs) are one of the most effective tools for preventing malaria in sub-Saharan Africa.

Objective

This study examined knowledge, attitude, and practice on the use of ITNs in the prevention of malaria among pregnant women and guardians of children under five in the Democratic Republic of the Congo.

Methods

A total of 5,138 pregnant women and guardians of children under five were interviewed.

Results

The majority of participants (>80%) knew the signs and symptoms of malaria; 81.6% reported having an ITN in the household, but 78.4% reported using it the night before the interview. Only 71.4% of pregnant women used ITN the night compared to 68.2% of children under five. In the Logistic Regression model, women who believed that it is normal to use ITNs were 1.9 times more likely to use it than those who did not (OR: 1.930); women who were confident in their abilities to use ITNs were 1.9 times more likely than those who were not confident (OR: 1.915); and women who had a good attitude towards ITNs were also more likely to use ITNs compared to those who did not (OR: 1.529).

Conclusion

New and innovative evidence-based behavior change interventions are needed to increase the utilization of ITNs among vulnerable groups.

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

Background

Continuous distribution of insecticide-treated nets (ITNs) is thought to be an effective mechanism to maintain ITN ownership and access between or in the absence of mass campaigns, but evidence is limited. A community-based ITN distribution pilot was implemented and evaluated in Toamasina II District, Madagascar, to assess this new channel for continuous ITN distribution.

Methods

Beginning 9 months after the December 2012 mass campaign, a community-based distribution pilot ran for an additional 9 months, from September 2013 to June 2014. Households requested ITN coupons from community agents in their village. After verification by the agents, households exchanged the coupon for an ITN at a distribution point. The evaluation was a two-stage cluster survey with a sample size of 1125 households. Counterfactual ITN ownership and access were calculated by excluding ITNs received through the community pilot.

Results

At the end of the pilot, household ownership of any ITN was 96.5%, population access to ITN was 81.5 and 61.5% of households owned at least 1 ITN for every 2 people. Without the ITNs provided through the community channel, household ownership of any ITN was estimated at 74.6%, population access to an ITN at 55.5%, and households that owned at least 1 ITN for 2 people at only 34.7%, 18 months after the 2012 campaign. Ownership of community-distributed ITNs was higher among the poorest wealth quintiles. Over 80% of respondents felt the community scheme was fair and simple to use.

Conclusions

Household ITN ownership and population ITN access exceeded RBM targets after the 9-month community distribution pilot. The pilot successfully provided coupons and ITNs to households requesting them, particularly for the least poor wealth quintiles, and the scheme was well-perceived by communities. Further research is needed to determine whether community-based distribution can sustain ITN ownership and access over the long term, how continuous availability of ITNs affects household net replacement behaviour, and whether community-based distribution is cost-effective when combined with mass campaigns, or if used with other continuous channels instead of mass campaigns.

Determination of the predictive factors of long-lasting insecticide-treated net ownership and utilisation in the Bamenda Health District of Cameroon

Background

Malaria is a serious health concern in Africa. In Cameroon, an endemic country where malaria remains a major public health problem, several control measures have been put in place among which the use of insecticide-treated bednets (LLINs/ITNs) is considered one of the core vector control strategies. However, the greatest challenges include ownership and utilisation by individuals and households. Factors such as age, marital status, gender, education and occupation of the household head, household size, knowledge of bednets, socioeconomic status, and environmental factors have been suggested to have an impact on bednet ownership and utilisation in different settings. The present study sought to determine bednet ownership and utilisation rates and to assess the impact of predictive factors on bednet ownership and use in the Bamenda Health District (BHD) of Cameroon.

Methods

A cross-sectional study involving 384 households was conducted in six health areas in the BHD. A structured and semi-structured questionnaire was used to collect data on demographic and household characteristics as well as information on their bednet ownership and utilisation. Descriptive statistics, bivariate and multivariate logistic regression analysis were performed.

Results

Frequency of bednet ownership was relatively high (63.5%) with LLINs being most abundant (91.9%); the majority of households (87.7%) obtained their bednets during the 2011 free distribution campaign. Utilisation was relatively high (69.3%), with negligence (29.3%) and heat discomfort (26.7%) accounting most for non-usage of bednets. Children less than 5 years (63%) and pregnant women (60%) most often used these nets. Households headed by a married couple, those with older household heads, household with smaller size (5–12 persons), and knowledge of bednets (good knowledge) had positive impacts on bednet ownership (p < 0.05). The gender of the household head (males), their educational level, environmental conditions (presence of suitable mosquito breeding sites), bednet number in households (greater number of bednets) and the prioritised groups (children < 5 and pregnant women) had positive impacts on bednet utilisation in households (p < 0.05). There was a negative association between bednet ownership and utilisation by households as bednet ownership was high and utilisation of these nets was low. Marital status and age of household head, household size, and knowledge of bednets had impacts on bednet ownership while gender and educational level of the household head, environmental suitability, the number of bednets and the two prioritised groups had an impact on bednet usage.

Conclusion

These factors may be relevant for policy makers and in decision making for the intensification of campaign strategies to ensure more effective subsequent distribution campaigns in the BHD and beyond.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4155-5) contains supplementary material, which is available to authorized users.

Bio-efficacy, physical integrity, community usage and washing practices of mosquito nets treated with ICON MAXX long-lasting insecticidal treatment in India

BACKGROUND

New brands of potential long lasting insecticide nets (LLINs) and LLIN treatment kits require field evaluation before they are used in a vector control programme.

OBJECTIVES

The aim of this study was to evaluate the bio-efficacy, usage, washing practice and physical integrity of nets treated with LLIN treatment kit, ICON MAXX in a phase III field trial in Odisha state, India.

METHODS

A total of 300 polyester nets treated with ICON MAXX and 140 polyester nets treated conventionally with lambda-cyhalothrin CS 2.5% ITNs were distributed. The bio-efficacy was evaluated with WHO cone bioassay. The chemical analysis of netting pieces was done at the beginning, after 12 and 36 months of the trial.

FINDINGS

After one year of distribution of nets, the bioassay showed 100% mortality on both ITNs and ICON MAXX treated nets. At 36 months, the overall pass rate was 58.8% and the mean lambda-cyhalothrin content of LLINs was 34.5 mg ai/m2, showing a loss of 44.4% of the original concentration.

CONCLUSION

ICON MAXX treated LLIN was found to retain bio-efficacy causing 97% knockdown of Anopheles stephensi up to 30 months and met the WHOPES criteria. However, the desired bio-efficacy was not sustained up to 36 months.

Operational challenges to continuous LLIN distribution: a qualitative rapid assessment in four countries

BACKGROUND

The World Health Organization recommends that long-lasting insecticidal nets (LLINs) for malaria prevention should be distributed continuously through antenatal care (ANC) and the expanded programme on immunization (EPI) in addition to mass campaigns. Despite these recommendations, the continuous distribution (CD) of LLIN distribution through ANC and EPI is not policy in many countries, and where there is a policy, implementation is incomplete. This study aims to identify the operational strengths and weaknesses of LLINs CD in four country programmes in sub-Saharan Africa.

METHODS

A qualitative rapid assessment process was conducted using semi-structured individual and group interviews at the national, sub-national, and facility level in four countries. Seventy participants were included (23 in Kenya, 13 in Malawi, 18 in Mali and 16 in Rwanda), drawn from malaria programmes, ANC and EPI programmes, government logistics units, and partner organizations. Interviews were structured to identify themes within a health systems approach. Policy and guideline documents and data collection tools were reviewed as a means of triangulation. Data analysis focused on pre-determined and emergent themes.

RESULTS

The four countries used a wide variety of management systems for the supply of LLINs to routine services. Issues related to quantification, supply logistics and data collection all contributed to stock-outs at facility level. None of the four countries had guidelines for responding to stock-outs or system enabling local staff to request additional supplies of LLINs. In all four countries, data collection of LLIN distribution was incomplete or absent at facility level, and such data were not used for planning. Training of staff at the facility level was implemented less frequently than national and sub-national staff would have preferred. Logistics systems, independent of other commodities, and in-country partner support strengthened the continuous distribution of LLINs.

CONCLUSIONS

In these countries, stock-outs were the most important single obstacle to the smooth operations of continuous LLIN distribution. Stock-outs can be avoided if facilities have the capacity to place orders for LLIN resupply as needed. Revised data collection and management systems for LLIN distribution have the potential to increase coverage of the target populations by improving LLIN stock-out response, and strengthening monitoring and evaluation of distribution.

Tuberculosis in pregnancy: an estimate of the global burden of disease

BACKGROUND

The estimated number of maternal deaths in 2013 worldwide was 289 000, a 45% reduction from 1990. Non-obstetric causes such as infectious diseases including tuberculosis now account for 28% of maternal deaths. In 2013, 3·3 million cases of tuberculosis were estimated to occur in women globally. During pregnancy, tuberculosis is associated with poor outcomes, including increased mortality in both the neonate and the pregnant woman. The aim of our study was to estimate the burden of tuberculosis disease among pregnant women, and to describe how maternal care services could be used as a platform to improve case detection.

METHODS

We used publicly accessible country-level estimates of the total population, distribution of the total population by age and sex, crude birth rate, estimated prevalence of active tuberculosis, and case notification data by age and sex to estimate the number of pregnant women with active tuberculosis for 217 countries. We then used indicators of health system access and tuberculosis diagnostic test performance obtained from published literature to determine how many of these cases could ultimately be detected.

FINDINGS

We estimated that 216 500 (95% uncertainty range 192 100-247 000) active tuberculosis cases existed in pregnant women globally in 2011. The greatest burdens were in the WHO African region with 89 400 cases and the WHO South East Asian region with 67 500 cases in pregnant women. Chest radiography or Xpert RIF/MTB, delivered through maternal care services, were estimated to detect as many as 114 100 and 120 300 tuberculosis cases, respectively.

Prioritizing pregnant women for long-lasting insecticide treated nets through antenatal care clinics

Jenny Hill and colleagues discuss the importance of antenatal care services in providing pregnant women with a long-lasting insecticide treated net for the prevention of malaria in both the mother and infant. Please see later in the article for the Editors' Summary

Household malaria knowledge and its association with bednet ownership in settings without large-scale distribution programs: Evidence from rural Madagascar

Background

Insecticide–treated bednets are effective at preventing malaria. This study focuses on household–level factors that are associated with bednet ownership in a rural area of Madagascar which had not been a recipient of large–scale ITN distribution.

Methods

Data were gathered on individual and household characteristics, malaria knowledge, household assets and bednet ownership. Principal components analysis was used to construct both a wealth index based on household assets and a malaria knowledge index based on responses to questions about malaria. Bivariate and multivariate regressions were used to determine predictors of household bednet ownership and malaria knowledge.

Results

Forty–seven of 560 households (8.4%) owned a bednet. In multivariate analysis, higher level of malaria knowledge among household members was the only variable significantly associated with bednet ownership (odds ratio 3.72, P < 0.001). Among respondents, predictors of higher malaria knowledge included higher education levels, female sex and reporting fever as the most frequent or dangerous illness in the community. Household wealth was not a significant predictor of bednet ownership or respondent malaria knowledge.

Conclusion

In this setting of limited supply of affordable bednets, malaria knowledge was associated with an increased probability of household bednet ownership. Further studies should determine how such malaria knowledge evolves and if malaria–specific education programs could help overcome the barriers to bednet ownership among at–risk households living outside the reach of large–scale bednet distribution programs.

Ownership and utilisation of long lasting insecticide treated nets following free distribution campaign in South West Nigeria

Introduction

Malaria has proven to be the most horrendous and intractable amongst the health problems confronting countries in the sub-Saharan Africa. This study aims to determine the ownership and utilisation of long lasting insecticide treated nets following free distribution campaign in a state in South West Nigeria.

Methods

Multi-stage sampling technique was used to recruit 2560 households spread across the 16 LGAs of the state. Interviewer administered standardized questionnaire was used for the survey. Data analysis was done using Stata 10 software.

Results

Sixty eight point six percent (68.6%) of the households had at least one under-five child living in the household while 32.6% had at least one pregnant woman living in the household. A total of 2440 (95.3%) households received LLIN during the campaign. Overall, the utilization rate for all respondents was 58.5%. Despite the fact that 2440 households received LLINs during the campaign, only 84.3% of them were seen to have hung theirs during the survey.

Conclusion

Coverage and ownership of LLINs increased significantly following the free distribution campaign. There was a discrepancy between net possession and net use with rate of use lower than possession. Post distribution educational campaign should be incorporated into future distribution campaigns to help increase net utilisation.

Utilisation of insecticide treated nets among pregnant women in Gulu: a post conflict district in northern Uganda

BACKGROUND

Malaria during pregnancy causes severe anaemia, placental malaria or death to the mother while the fetus may be aborted or stillborn.

OBJECTIVE

To establish the prevalence and factors associated with Insecticide Treated Net (ITN) utilisation among pregnant women in a post conflict Internally Displaced Persons (IDP) camps of Gulu district.

METHODS

We conducted cross-sectional study in 20 IDP camps in which 769 pregnant women were interviewed for ITN utilisation the night before the survey. The 20 IDP camps were selected using simple random sampling technique as clusters. Households that had pregnant women were then consecutively selected. Data were entered in EpiData 3.1 and analyzed using STATA11.

RESULTS

35% of pregnant women (95% CI 31% - 38%) had utilised ITNs. Factors that promoted ITN utilisation includes: antenatal visit (AOR 1.90, p-value 0.000); ITN awareness (AOR 1.57, p-value 0.011), and willingness to purchase ITN (AOR 2.12, p-value 0.000). Factors which hinder ITN utilisation were: hours taken to reach health centre (AOR 0.64, p-value 0.050) and being single/widow/divorced (AOR 0.22, p-value 0.000).

CONCLUSION

Majority of the respondents were not utilising ITN. Therefore, leaders in Gulu district should encourage pregnant woman to acquire and use ITN to reduce their vulnerability to malaria.

Ownership and use of insecticide-treated nets during pregnancy in sub-Saharan Africa: a review

Over the past decade, significant gains have been made in the implementation of malaria prevention measures in pregnancy in sub-Saharan Africa, including the distribution of insecticide-treated nets (ITNs). These have been shown to cause a reduction in the incidence of malaria and its consequences such as maternal anaemia, stillbirths and intrauterine growth restriction. Currently most nations in Africa have policies for distributing ITNs to pregnant women through various mechanisms, however coverage remains well below the targets. This review summarizes recent evidence regarding the correlation between ownership and use of ITNs and the determinants of both, in pregnancy in sub-Saharan Africa, and reviews interventions directed at improving coverage. A review of the literature using Pubmed, CINAHL and scanning of reference lists was conducted in October 2012 and 59 articles were selected for final review. The research obtained was a mixture of national and district level surveys, and a narrative synthesis of the data was undertaken. Ownership of ITNs varied from as low as 3% to greater than 80%, and the main determinants were found to be education level, knowledge of malaria, community involvement, socio-economic status and parity, although the significance of each varied between the different settings and studies reviewed. In more than half the settings where data were available, the combination of lack of availability and lack of use of an available net meant that less than half of all pregnancies received the recommended intervention. Supply and cost remain major barriers to achieving optimal coverage, but the additional important contributor to reduced efficiency of intervention was the clear discrepancy between ownership and use, with available ITN use below 60% in several settings. Cited reasons for not using an ITN, where one was available, included discomfort, problems with hanging up nets and lack of space, low awareness of need, and seasonal variations in use. These findings highlight the need for context-specific approaches and educational components to be incorporated into ITN distribution programmes to address some of the reasons why some pregnant women do not use the ITNs they own.

Factors affecting the delivery, access, and use of interventions to prevent malaria in pregnancy in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Malaria in pregnancy has important consequences for mother and baby. Coverage with the World Health Organization-recommended prevention strategy for pregnant women in sub-Saharan Africa of intermittent preventive treatment in pregnancy (IPTp) and insecticide-treated nets (ITNs) is low. We conducted a systematic review to explore factors affecting delivery, access, and use of IPTp and ITNs among healthcare providers and women.

METHODS AND RESULTS

We searched the Malaria in Pregnancy Library and Global Health Database from 1 January 1990 to 23 April 2013, without language restriction. Data extraction was performed by two investigators independently, and data was appraised for quality and content. Data on barriers and facilitators, and the effect of interventions, were explored using content analysis and narrative synthesis. We conducted a meta-analysis of determinants of IPTp and ITN uptake using random effects models, and performed subgroup analysis to evaluate consistency across interventions and study populations, countries, and enrolment sites. We did not perform a meta-ethnography of qualitative data. Ninety-eight articles were included, of which 20 were intervention studies. Key barriers to the provision of IPTp and ITNs were unclear policy and guidance on IPTp; general healthcare system issues, such as stockouts and user fees; health facility issues stemming from poor organisation, leading to poor quality of care; poor healthcare provider performance, including confusion over the timing of each IPTp dose; and women's poor antenatal attendance, affecting IPTp uptake. Key determinants of IPTp coverage were education, knowledge about malaria/IPTp, socio-economic status, parity, and number and timing of antenatal clinic visits. Key determinants of ITN coverage were employment status, education, knowledge about malaria/ITNs, age, and marital status. Predictors showed regional variations.

CONCLUSIONS

Delivery of ITNs through antenatal clinics presents fewer problems than delivery of IPTp. Many obstacles to IPTp delivery are relatively simple barriers that could be resolved in the short term. Other barriers are more entrenched within the overall healthcare system or socio-economic/cultural contexts, and will require medium- to long-term strategies. Please see later in the article for the Editors' Summary.

Indifferent to disease: a qualitative investigation of the reasons why some Papua New Guineans who own mosquito nets choose not to use them

This paper presents findings from a qualitative study designed to explore the reasons why some Papua New Guineans who own mosquito nets choose not to use them, whether on a regular or episodic basis. In-depth interviews (IDIs) were conducted with a sub-sample (n = 44) of participants in a country wide household survey who reported owning or having access to a mosquito net, but not having slept under a mosquito net the night prior to survey. All IDIs were completed between December 2010 and June 2011. Analysis was informed by a general inductive methodology. Multiple impediments to regular mosquito net use were identified by study participants, although all were broadly grouped into the inter-related categories of net-, environmental- or human-factors. Indifference emerged as the most influential impediment towards regular net use presenting as a general attitudinal context in which a majority of participant responses were grounded. A lack of knowledge regarding malaria transmission pathways or the utility of mosquito nets did not appear to underlie this indifference. Rather, the indifference appeared to be rooted in a lack of fear of malaria infection cultivated through lived experience. A wide range of interventions could potentially promote greater mosquito net use amongst this population. However, the basis of any intervention strategy, given the pervasive indifferent attitude towards regular mosquito net use, should be to render individual mosquito net use as easy and as convenient as possible and to promote complementary malaria control strategies where appropriate.

Determinants of use of insecticide treated nets for the prevention of malaria in pregnancy: Jinja, Uganda

Background

One established means of preventing the adverse consequences of malaria during pregnancy is sleeping under an insecticide treated net (ITN) throughout pregnancy. Despite increased access to this intervention over time, consistent ITN use during pregnancy remains relatively uncommon in sub-Saharan Africa.

Methodology/Principal Findings

We sought to identify determinants of ITN use during pregnancy. Utilizing a population-based random sample, we interviewed 500 women living in Jinja, Uganda, who had been pregnant in the past year. ITN ownership at the start of pregnancy was reported by 359 women (72%) and 28 women (20%) acquired an ITN after the first trimester of pregnancy. Among 387 ITN owners, 73% reported either always sleeping under the ITN during all trimesters of pregnancy, or after acquiring their net. Owning more than 1 net was slightly associated with always sleeping under an ITN during pregnancy (RR: 1.13; 95% CI: 1.00, 1.28). Women who always slept under an ITN during pregnancy were more likely to be influenced by an advertisement on the radio/poster than being given an ITN free of charge (RR: 1.48; 95% CI: 1.24, 1.76). No differences were found between other socio-demographic factors, pregnancy history, ANC use or socio-cultural factors.

Conclusions/Significance

While self-reported ITN ownership and use was common throughout pregnancy, we were unable to pinpoint why a sizable fraction of Ugandan women did not always adhere to recommendations for use of an ITN during pregnancy. More data are needed on the capacity of individual households to support the installation of ITNs which may provide insight into interventions targeted at improving the convenience and adherence of daily ITN use.

Ownership and use of insecticide-treated nets in Oromia and Amhara regional states of Ethiopia two years after a nationwide campaign

OBJECTIVE

To evaluate the ownership and use of insecticide-treated nets (ITNs) by the local community 2 years after a free distribution campaign in Ethiopia.

METHODS

This is a population-based survey using a two-stage cluster sample design in 115 randomly selected clusters in Oromia and Amhara regional states of Ethiopia, performed in June 2009. Data on the possession and use of ITNs were collected using structured and pre-tested questionnaires through house-to-house visits. Bivariate and multivariate logistic regression analyses were performed to examine the effect of participant's malaria knowledge, location and ITN characteristics on the use of ITNs.

RESULTS

A total of 2874 households participated in the study, and 90.6% of the study population was knowledgeable about ITNs. About 49.1% of households reported at least one ITN; 28.4% owned two or more. ITN coverage was significantly lower in Oromia (34.9%) than in Amhara (76.8%, P<0.001). The average number of ITNs per ITN-owning household was 1.8. In all surveyed households, only 21.8% of all family members, 29.4% of all children under the age of 5 years and 23.2% of all pregnant women had slept under an ITN the night preceding the survey. Among ITN-owning households, 63.0% of all children under the age of 5 years and 52.1% of pregnant women had slept under an ITN the night before the survey. Using multivariate analysis, factors significantly associated with ITN use were number of ITNs in the household, number of ITNs hung over the bed in the household, women's knowledge of ITNs and women's lack of problem in using ITNs, whereas region, area of residence and ITN status were not.

CONCLUSIONS

Household ITN ownership and use remain below the current Roll Back Malaria targets of universal coverage. A replacement strategy is urgently needed to scale-up coverage and use of ITNs.

Best practices for an insecticide-treated bed net distribution programme in sub-Saharan eastern Africa

Insecticide-treated bed nets are the preeminent malaria control means; though there is no consensus as to a best practice for large-scale insecticide-treated bed net distribution. In order to determine the paramount distribution method, this review assessed literature on recent insecticide treated bed net distribution programmes throughout sub-Saharan Eastern Africa. Inclusion criteria were that the study had taken place in sub-Saharan Eastern Africa, targeted malaria prevention and control, and occurred between 1996 and 2007. Forty-two studies were identified and reviewed. The results indicate that distribution frameworks varied greatly; and consequently so did outcomes of insecticide-treated bed net use. Studies revealed consistent inequities between urban and rural populations; which were most effectively alleviated through a free insecticide-treated bed net delivery and distribution framework. However, cost sharing through subsidies was shown to increase programme sustainability, which may lead to more long-term coverage. Thus, distribution should employ a catch up/keep up programme strategy. The catch-up programme rapidly scales up coverage, while the keep-up programme maintains coverage levels. Future directions for malaria should include progress toward distribution of long-lasting insecticide-treated nets.

Reported reasons for not using a mosquito net when one is available: a review of the published literature

Background

A review of the barriers to mosquito net use in malaria-endemic countries has yet to be presented in the published literature despite considerable research interest in this area. This paper partly addresses this gap by reviewing one component of the evidence base; namely, published research pertaining to self-reported reasons for not using a mosquito net among net 'owning' individuals. It was anticipated that the review findings would potentially inform an intervention or range of interventions best suited to promoting greater net use amongst this group.

Method

Studies were sought via a search of the Medline database. The key inclusion criteria were: that study participants could be identified as owning a mosquito net or having a mosquito net available for use; that these participants on one or more occasions were identified or self-reported as not using the mosquito net; and that reasons for not using the mosquito net were reported. Studies meeting these criteria were included irrespective of mosquito net type.

Results

A total of 22 studies met the inclusion criteria. Discomfort, primarily due to heat, and perceived (low) mosquito density were the most widely identified reason for non-use. Social factors, such as sleeping elsewhere, or not sleeping at all, were also reported across studies as were technical factors related to mosquito net use (i.e. not being able to hang a mosquito net or finding it inconvenient to hang) and the temporary unavailability of a normally available mosquito net (primarily due to someone else using it). However, confidence in the reported findings was substantially undermined by a range of methodological limitations and a dearth of dedicated research investigation.

Conclusions

The findings of this review should be considered highly tentative until such time as greater quantities of dedicated, well-designed and reported studies are available in the published literature. The current evidence-base is not sufficient in scope or quality to reliably inform mosquito net promoting interventions or campaigns targeted at individuals who own, but do not (reliably) use, mosquito nets.

The importance of education to increase the use of bed nets in villages outside of Kinshasa, Democratic Republic of the Congo

Background

Malaria is the most prominent disease in the Democratic Republic of the Congo (DRC), and long-lasting insecticide-treated nets (LLINs) have been distributed free of charge since 2006 to combat the disease. However, the success of this bed net campaign depends on sufficient bed net use in all age groups. This study was designed to examine the factors affecting bed net use in villages outside of Kinshasa.

Methods

Two villages along the Congo River, totalling 142 households with 640 residents, were surveyed using a standard questionnaire. The interview determined the number, ages, and sexes of family members; the education level of the family head; the number, colour, and type of nets owned; and the number of nets used in the previous night. The size of house was also measured, and numbers of rooms and beds were recorded. These variables were examined to reveal important factors that affect bed net use.

Results

A total of 469 nets were counted, and nearly all nets were white LLINs. Of these nets, 229 (48.8%) nets were used by 284 (44.4%) residents. Bed nets were used by over 90% of children 5 to 15 years of age, whereas less than 50% of the residents in other age groups used bed nets. The important variables affecting bed net use were numbers of beds and rooms in the house and the education level of the family head of household.

Conclusion

Education was the most important factor affecting bed net use in the villages outside Kinshasa. Development of an educational programme, particularly one directed toward parents, is necessary to reduce misconceptions and increase prevalence of bed net use among all age groups.

Methods for evaluating delivery systems for scaling-up malaria control intervention

Background

Despite increased resources over the past few years the coverage of malaria control interventions is still inadequate to reach national and international targets and achieve the full potential of the interventions to improve population health. One of the reasons for this inadequate coverage of efficacious interventions is the limited understanding of the optimum delivery systems of the interventions in different contexts. Although there have been debates about how to deliver interventions, the methods for evaluating the effectiveness of different delivery systems have rarely been discussed. Delivery of interventions is relatively complex and a thorough evaluation would need to look holistically at multiple steps in the delivery process and at multiple factors influencing the process. A better understanding of the strength of the evidence on delivery system effectiveness is needed in order to optimise delivery of efficacious interventions.

Methods

A literature review was conducted of methods used to evaluate delivery systems for insecticide treated nets, intermittent preventive treatment in pregnant women, and treatment for malaria in children.

Results

The methodology of delivery system evaluations varied. There were inconsistencies between objectives and methods of the evaluations including inappropriate outcome measures and unnecessary controls. There were few examples where the delivery processes were adequately described, or measured. We propose a cross sectional observational study design with attribution of the outcomes to a specific delivery system as an appropriate method for evaluating delivery systems at scale.

Conclusions

The proposed evaluation framework is adaptable to natural experiments at scale, and can be applied using data from routine surveys such as the Demographic and Health Surveys, modified by the addition of one to two questions for each intervention. This framework has the potential to enable wider application of rigorous evaluations and thereby improve the evidence base on which decisions about delivery systems for malaria control and other public health interventions are taken.

Long-lasting insecticide-treated net usage in eastern Sierra Leone - the success of free distribution

OBJECTIVE

Médecins Sans Frontières (MSF) runs a malaria control project in Bo and Pujehun districts (population 158 000) that includes the mass distribution, routine delivery and demonstration of correct use of free, long-lasting insecticide-treated nets (LLINs). In 2006/2007, around 65 000 LLINs were distributed. The aim of this follow-up study was to measure LLIN usage and ownership in the project area.

METHODS

Heads of 900 randomly selected households in 30 clusters were interviewed, using a standardized questionnaire, about household use of LLINs. The condition of any LLIN was physically assessed.

RESULTS

Of the 900 households reported, 83.4% owning at least one LLIN. Of the 16.6% without an LLIN, 91.9% had not participated in the MSF mass distribution. In 94.1% of the households reporting LLINs, the nets were observed hanging correctly over the beds. Of the 1135 hanging LLINs, 75.2% had no holes or 10 or fewer finger-size holes. The most common source of LLINs was MSF (75.2%). Of the 4997 household members, 67.2% reported sleeping under an LLIN the night before the study, including 76.8% of children under 5 years and 73.0% of pregnant women.

CONCLUSION

Our results show that MSF achieved good usage with freely distributed LLINs. It is one of the few areas where results almost achieve the new targets set in 2005 by Roll Back Malaria to have at least 80% of pregnant women and children under 5 years using LLINs by 2010.

Plasmodium infection and its risk factors in eastern Uganda

BACKGROUND

Malaria is a leading cause of disease burden in Uganda, although surprisingly few contemporary, age-stratified data exist on malaria epidemiology in the country. This report presents results from a total population survey of malaria infection and intervention coverage in a rural area of eastern Uganda, with a specific focus on how risk factors differ between demographic groups in this population.

METHODS

In 2008, a cross-sectional survey was conducted in four contiguous villages in Mulanda, sub-county in Tororo district, eastern Uganda, to investigate the epidemiology and risk factors of Plasmodium species infection. All permanent residents were invited to participate, with blood smears collected from 1,844 individuals aged between six months and 88 years (representing 78% of the population). Demographic, household and socio-economic characteristics were combined with environmental data using a Geographical Information System. Hierarchical models were used to explore patterns of malaria infection and identify individual, household and environmental risk factors.

RESULTS

Overall, 709 individuals were infected with Plasmodium, with prevalence highest among 5-9 year olds (63.5%). Thin films from a random sample of 20% of parasite positive participants showed that 94.0% of infections were Plasmodium falciparum and 6.0% were P. malariae; no other species or mixed infections were seen. In total, 68% of households owned at least one mosquito although only 27% of school-aged children reported sleeping under a net the previous night. In multivariate analysis, infection risk was highest amongst children aged 5-9 years and remained high in older children. Risk of infection was lower for those that reported sleeping under a bed net the previous night and living more than 750 m from a rice-growing area. After accounting for clustering within compounds, there was no evidence for an association between infection prevalence and socio-economic status, and no evidence for spatial clustering.

CONCLUSION

These findings demonstrate that mosquito net usage remains inadequate and is strongly associated with risk of malaria among school-aged children. Infection risk amongst adults is influenced by proximity to potential mosquito breeding grounds. Taken together, these findings emphasize the importance of increasing net coverage, especially among school-aged children.

Acceptability, willing to purchase and use long lasting insecticide treated mosquito nets in Orissa State, India

Long lasting insecticide treated nets (LLINs) that require no re-treatment have been advocated as an effective tool against malaria transmission. However, success of this community based intervention measure largely depends on its acceptability and proper usage by the target population, besides assuring access to bed nets. To determine the acceptability of LLIN, its usage and people's willingness to buy the net, a study was conducted in two tribal districts viz., Malkangiri (with ongoing ITN programme) and Koraput (no ITN programme) of Orissa State, India. Both qualitative and quantitative data collection methods were used to collect information regarding the objective of the study. A total of 2457 LLINs (Olyset Nets) were distributed in the selected villages of these districts at free of cost. In the study villages of Malkangiri, 58% of the households had either ITNs (73%) or other types of mosquito nets aside from the LLINs and in the villages of Koraput, only 8% had other nets, as majority (96%) informed that buying nets from market was not affordable to them. Physical verification of the nets during the house visits revealed that 75.4% and 83% (in ITNs and non-ITNs villages, respectively) of the LLINs and 76% of the other nets (including ITNs) were used by the respondents, the night before the survey as nets were in a hanging position at the time of the visit. Majority of the respondents (76-98%) felt that reduction of mosquito bites as the main perceived benefit of using the LLINs. About 55% and 67% of the respondents from non-ITNs and ITNs areas, respectively, expressed their willingness to buy the LLINs. Among them, 76.8% and 94.7% offered to pay INR<100 for a net and also ready to buy it by cash payment. Social marketing of LLINs at a subsidized price or free supply to the deserving sections of people (socially/economically poor and/or under-privileged) and ensuring the availability of nets during harvesting season could encourage people to buy and use LLINs.

How equitable is bed net ownership and utilisation in Tanzania? A practical application of the principles of horizontal and vertical equity

Background

Studies show that the burden of malaria remains huge particularly in low-income settings. Although effective malaria control measures such as insecticide-treated nets (ITNs) have been promoted, relatively little is known about their equity dimension. Understanding variations in their use in low-income settings is important for scaling up malaria control programmes particularly ITNs. The objective of this paper is to measure the extent and causes of inequalities in the ownership and utilisation of bed nets across socioeconomic groups (SEGs) and age groups in Tanga District, north-eastern Tanzania.

Methods

A questionnaire was administered to heads of 1,603 households from rural and urban areas. Households were categorized into SEGs using both an asset-based wealth index and education level of the household head. Concentration indices and regression-based measures of inequality were computed to analyse both vertical and horizontal inequalities in ownership and utilisation of bed nets. Focus Group Discussions (FGDs) were used to explore community perspectives on the causes of inequalities.

Results

Use of ITNs remained appallingly low compared to the RBM target of 80% coverage. Inequalities in ownership of ITNs and all nets combined were significantly pro-rich and were much more pronounced in rural areas. FGDs revealed that lack of money was the key factor for not using ITNs followed by negative perceptions about the effect of insecticides on the health of users. Household SES, living within the urban areas and being under-five were positively associated with bed net ownership and/or utilisation.

Conclusion

The results highlight the need for mass distribution of ITN; a community-wide programme to treat all untreated nets and to promote the use of Long-Lasting Insecticidal nets (LLINs) or longer-lasting treatment of nets. The rural population and under-fives should be targeted through highly subsidised schemes and mass distribution of free nets. Public campaigns are also needed to encourage people to use treated nets and mitigate negative perceptions about insecticides.