Equity implications of coverage and use of insecticide treated nets distributed for free or with co-payment in two districts in Tanzania: A cross-sectional comparative household survey

Financing for equity for women's, children's and adolescents' health in low- and middle-income countries: A scoping review

Over the past few decades, the world has witnessed considerable progress in women's, children's and adolescents' health (WCAH) and the Sustainable Development Goals (SDGs). Yet deep inequities remain between and within countries. This scoping review aims to map financing interventions and measures to improve equity in WCAH in low- and middle-income countries (LMICs). This scoping review was conducted following Joanna Briggs Institute (JBI) guidance for conducting such reviews as well as the PRISMA Extension for Scoping Reviews (PRISMA-ScR) for reporting scoping reviews. We searched Medline, PubMed, EMBASE and the World Health Organization's (WHO) Global Index Medicus, and relevant websites. The selection process was conducted in duplicate and independently. Out of 26 355 citations identified from electronic databases, relevant website searches and stakeholders' consultations, 413 studies were included in the final review. Conditional cash transfers (CCTs) (22.3%), health insurance (21.4%), user fee exemptions (18.1%) and vouchers (16.9%) were the most reported financial interventions and measures. The majority were targeted at women (57%) and children (21%) with others targeting adolescents (2.7%) and newborns (0.7%). The findings highlighted that CCTs, voucher programs and various insurance schemes can improve the utilization of maternal and child health services for the poor and the disadvantaged, and improve mortality and morbidity rates. However, multiple implementation challenges impact the effectiveness of these programmes. Some studies suggested that financial interventions alone would not be sufficient to achieve equity in health coverage among those of a lower income and those residing in remote regions. This review provides evidence on financing interventions to address the health needs of the most vulnerable communities. It can be used to inform the design of equitable health financing policies and health system reform efforts that are essential to moving towards universal health coverage (UHC). By also unveiling the knowledge gaps, it can be used to inform future research on financing interventions and measures to improve equity when addressing WCAH in LMICs.

Strategies to improve the quality of midwifery care and developing midwife-centered care in Iran: analyzing the attitudes of midwifery experts

BACKGROUND

In recent years, extensive studies have been designed and performed in the context of providing midwifery care in developed countries, which has been unfortunately neglected in some low resources and upper middle-income countries such as Iran. This study was conducted to identify the best strategies for improving the quality of midwifery care and developing midwife-centered care in Iran.

METHODS

This was a qualitative study using focus group discussion and content analysis method. Data were collected from 121 participants including midwifery board members, gynecologists, heads of midwifery departments, midwifery students, in charge midwives in hospitals, and midwives in the private sector. Focused-group discussions were used for data collection, and data were analyzed using content analysis method.

RESULTS

The main themes extracted from the participants' statements regarding improving the quality of midwifery care were as follows: Promotion and development of education, Manpower management, Rules, and regulations and standards for midwifery services, and Policy making.

CONCLUSION

This study showed that to improve midwifery care, health policy makers should take into account both the quality and quantity of midwifery education, and promote midwifery human resources through employment. Furthermore, insurance support, encouragement, supporting and motivating midwives, enhancing and improving the facilities, providing hospitals and maternity wards with cutting-edge equipment, promoting and reinforcing the position of midwives in the family doctor program, and using a referral system were the strategies proposed by participants for improving midwifery care. Finally, establishing an efficient and powerful monitoring system to control the practice of gynecologists and midwives, promoting the collaborative practice of midwives and gynecologists, and encouraging team-work with respect to midwifery care were other strategies to improve the midwifery services in Iran. Authorities and policymakers may set the stage for developing high quality and affordable midwifery care by relying on the strategies presented in this study.

Coverage and usage of insecticide treated nets (ITNs) within households: associated factors and effect on the prevalance of malaria parasitemia in the Mount Cameroon area

Background

Insecticide-treated nets (ITNs) are a widely used tool that has been proven to be effective in the prevention and control of malaria in malaria endemic countries. However, usage varies among households and can greatly affect the benefits of ITNs as a control tool for malaria transmission. This study determined the coverage and usage of ITNS as well as associated factors and the effect of coverage and usage on the prevalence of malaria parasitemia within households in the Mount Cameroon area.

Methods

A cross-sectional survey was conducted between August and September 2014 in six communities within the Mount Cameroon area. Households within the communities were enrolled through multistage sampling and household survey was done using a structured questionnaire. Capillary blood was collected for malaria parasite determination. Data was analysed using SPSS version 20 for windows. Differences in proportions were assessed using the Chi-square test while factors affecting ITNs usage were assessed in multivariate logistic regression at a statistical significance of P ≤ 0.05.

Results

A total of 504 households were surveyed, 1564 bed spaces reported while 915(58.5, 95% CI: 56.1–60.9) of the bed spaces had nets and 391(77.6, 95% CI, 74.0–80.2) of the households had at least one bed net. The odds of using ITNs was 2 folds higher (OR = 2.41; 95% CI 1.58–3.69 p = 0.001) and 3 folds higher (OR = 3.149, 95% CI 1.53–6.47 p = 0.002) among houses with 5 to 9 occupants and above 10 occupants respectively when compared to houses with less than 5 occupants. In addition, Individuals living in cement block houses were less likely to use ITNs.

Compared to those living in wooden houses (OR = 0.488, 95% CI: 0.269–0.885; p = 0 .018). Rural communities had lower ITN coverage compared to semi-urban communities (p = 0.0001). Increase in ITNs coverage significantly reduces malaria prevalence (correlation − 0.899, p = 0.015).

Conclusion

Despite the efforts made to scale up ITN distribution so that universal coverage can be attained, coverage remains low. Increasing coverage and putting in place a mechanism to replace torn nets will go a long way reduce the prevalence of malaria parasitemia.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7555-x) contains supplementary material, which is available to authorized users.

A subnational profiling analysis reveals regional differences as the main predictor of ITN ownership and use in Nigeria

BACKGROUND

To reduce the malaria burden in Nigeria, the country is scaling up prevention and treatment interventions, especially household ownership and use of insecticide-treated nets (ITNs). Nevertheless, large gaps remain to achieve the goals of the National Malaria Strategic Plan 2014-2020 of universal access to ITNs and their increased use. To inform the targeting of intervention strategies and to maximize impact, the authors conducted a sub-national profiling of household ITN ownership and use in the general population to identify key predictors of ITN ownership and use, and the sub-groups that are at higher risk of low ITN coverage and use.

METHODS

The authors conducted a secondary analysis of data from the 2015 Nigeria Malaria Indicator Survey. Using the Chi square automatic interaction detector (CHAID) and multiple logistic regression analysis, the authors examined the key predictors of ITN ownership and use in the general population throughout Nigeria.

RESULTS

The CHAID models identified region of the country as the best predictor of household ownership of at least one ITN and its use in the general population, with higher ownership and use observed in the northern regions. The odds of a household owning an ITN were five times greater in the North West region compared with the North Central region (odds ratio [OR] = 5.47, 95% confidence interval [CI] 4.46-6.72, p < 0.001). The odds of ITN use were two times greater for those living in the North West region compared with the North Central region (OR = 2.04, 95% CI 1.73-2.41, p < 0.001). Other significant predictors were household size, head of household education level, household wealth quintile, and place of residence. The CHAID gain index results identified households in the South West, North Central and South Central regions with low ITN ownership, and the general population in the South South, South East and North Central regions with low ITN use.

CONCLUSIONS

This study reveals regional differences in ITN ownership and use in Nigeria. Therefore, the findings from this analysis provide evidence that could inform the NMEP to better target future campaign and routine distribution of ITNs, to achieve universal access and increased use by 2020 in Nigeria.

Quantifying bias in measuring insecticide-treated bednet use: meta-analysis of self-reported vs objectively measured adherence

Background

Insecticide-treated bednets (ITNs) are recommended for use by 3.4 billion people at risk of malaria world-wide. Policy makers rely on measurements of ITN use to optimize malaria prevention efforts. Self-reports are the most common means of assessing ITN use, but self-reports may be biased in a way that reduces their reliability as a proxy for ITN adherence. This meta-analysis compared self-reported and two methods which are more objective measures of ITN use to explore whether self-reports overestimate actual ITN adherence.

Methods

A comprehensive search of electronic databases and hand searching reference lists resulted in screening 2885 records and 202 articles were read in full. Sixteen articles with comparable data were chosen for the meta-analysis. Comparable data was defined as self-reported and objectively measured ITN use (observation of a mounted ITN or surprise visits confirming use) at the same unit of analysis, covering the same time period and same population. A random effects model was used to determine a weighted average risk difference between self-reported and objectively measured ITN use. Additional stratified analyses were conducted to explore study heterogeneity.

Results

Self-reported ITN use is 8 percentage points (95% confidence interval CI: 3 to 13) higher than objectively measured ITN use, representing a 13.6% overestimation relative to the proportion measured as adherent to ITN use by objective measures. Wide variations in the discrepancies between self-reports and objective measures were unable to be explained using stratified analyses of variables including location, year of publication, seasonality and others.

Conclusions

Self-reports overestimate ITN adherence relative to objectively measured ITN use by 13.6% and do so in an unpredictable manner that raises questions about the reliability of using self-reported ITN use alone as a surveillance tool and a guide for making policy decisions.

Assessment of household ownership of bed nets in areas with and without artemisinin resistance containment measures in Myanmar

BACKGROUND

Myanmar lies in the Greater Mekong Subregion where there is artemisinin-resistant Plasmodium falciparum malaria. As the artemisinin compound is the pillar of effective antimalarial therapies, containing the spread of artemisinin resistance is a national and global priority. The use of insecticide-treated bed nets/long-lasting insecticidal nets (ITNs/LLINs) is the key intervention for ensuring the reduction of malaria transmission and the spread of resistant strains, and for eventually eliminating malaria. This study aimed at assessing household ownership of, access to, and utilization of bed nets in areas of Myanmar with and without artemisinin resistance containment measures.

METHODS

Secondary data from a nationwide community-based malaria survey conducted by the National Malaria Control Program in 2014 were analyzed. Based on evidence of artemisinin resistance, Myanmar was divided into tiers 1, 2, and 3: townships in tiers 1 and 2 were aggregated as the Myanmar Artemisinin Resistance Containment (MARC) areas and were compared with tier 3 townships, which were defined as non-MARC areas. The chi-square test was used to compare groups, and the level of significance was set at P ≤ 0.05.

RESULTS

Of the 6328 households assessed, 97.2% in both MARC and non-MARC areas had at least one bed net (any type), but only 63% of households had ITNs/LLINs. Only 44% of households in MARC areas and 24% in non-MARC areas had adequate numbers of ITNs/LLINs (one ITN/LLIN per two persons, P <  0.001). Nearly 44% of household members had access to ITNs/LLINs. Regarding the utilization of ITNs/LLINs, 45% of household members used them in MARC areas and 36% used them in non-MARC areas (P <  0.001, desired target = 100%). Utilization of ITNs/LLINs among children aged below five years and pregnant women (high malaria risk groups) was low, at 44% and 42%, respectively.

CONCLUSIONS

This study highlights the nationwide shortfalls in the ownership of, access to, and utilization of ITNs/LLINs in Myanmar, which is of particular concern in terms of containing the spread of artemisinin resistance. It highlights the need for priority attention to be paid and mobilization of resources in order to improve bed net coverage and utilization through bed net distribution and/or social marketing, information dissemination, and awareness-raising.

Prevention Efforts for Malaria

PURPOSE OF REVIEW

Malaria remains a global burden contributing to morbidity and mortality especially in children under 5 years of age. Despite the progress achieved towards malaria burden reduction, achieving elimination in more countries remains a challenge. This article aims to review the prevention and control strategies for malaria, to assess their impact towards reducing the disease burden and to highlight the best practices observed.

RECENT FINDINGS

Use of long-lasting insecticide-treated nets and indoor residual spraying has resulted a decline in the incidence and prevalence of malaria in Sub-Saharan Africa. Other strategies such as larval source management have been shown to reduce mosquito density but require further evaluation. New methods under development such as house improvement have demonstrated to minimize disease burden but require further evidence on efficacy. Development of the RTS,S/AS01 malaria vaccine that provides protection in under-five children has provided further progress in efforts of malaria control.

SUMMARY

There has been a tremendous reduction in malaria burden in the past decade; however, more work is required to fill the necessary gaps to eliminate malaria.

Insecticide-treated net ownership and utilization and factors that influence their use in Itang, Gambella region, Ethiopia: cross-sectional study

Background

Malaria remains a major public health problem in Ethiopia. Consequently, Ethiopia designed the 2011–2015, Malaria Prevention and Control Strategic Plan to fight the vector. It was discovered that most of the studies conducted on the use of insecticide-treated nets (ITNs) were not in line with the strategic plan of the country. This study aimed to assess ITN ownership and utilization, and includes barriers related to its use among the target-area population at household (HH) level.

Materials and methods

A cross-sectional design was employed in Itang for this study. Data were collected by trained nurses through face-to-face interview and observation. A total of 845 participants were selected through multistage sampling, and the size was determined by using a single-population proportion formula. EPI Info and SPSS was used for analysis, and all necessary statistical association was computed in order to explain the outcome variable through explanatory variables of this study.

Results

Among 845 HHs interviewed, 81.7% (690) had at least one ITN, while 52.3% (361) had used the ITN the night preceding the data-collection day. HH awareness of malaria prevention, number of ITNs, family size, number of family members sharing sleeping area/beds, sleeping patterns of adolescents, HH-head age, and inconvenience of using ITNs were found to be barriers to the use of ITNs in this study.

Conclusion and recommendation

The study concluded that very few HHs owned ITNs and there was very low usage of ITNs. In recommendation, the regional health bureau and district health office should consider bigger nets that can accommodate family members who share the same sleeping area/bed in the area.

Challenges in universal coverage and utilization of insecticide-treated bed nets in migrant plantation workers in Myanmar

Background

High coverage of the bed nets can reduce mortality and morbidity of mosquito-borne diseases including malaria. Although the migrant workers are at high risk of malaria, there are many hidden challenges in universal coverage and utilization of the insecticide-treated nets (ITNs) in this populations.

Methods

Cross sectional study was conducted in 170 migrant workers in palm oil plantation sites in Tanintharyi Region and 175 in rubber plantation sites in Mon State. A multistage stratified cluster sampling was applied to select the participants. During household visit, face-to-face interviews using structured pre-coded, pre tested questionnaires and direct observation on installation of the bed nets was conducted. Two focus group discussions in each site were done by sample stratified purposive sampling method mainly focused on effective utilization of bed nets.

Results

Among them, 332 (96.2%) had a bed net and 284 (82.3%) had an ITN, while 204 (59.1%) had unused extranets. Among the ITNs users, 28.9% reported problems including insecticide smell (56.9%), dizziness (20.2%), headache (12.8%) and itchiness (9.2%). More than 75% received ITNs from health authorities and NGOs free-of-charge. More than 70% wanted to buy a net but they were unaffordable for 64% of them. On observation, only five families could show no bed net, but 80% showed 1–3 ITNs. Consistent utilization in all seasons was noted in 189 (53.1%), that was higher in palm oil plantation than rubber plantation workers (p = 0.0001) due to the nature of the work at night. Perceived malaria risk was also significantly higher ITNs consistent users than non-users (p = 0.0004) and better willingness to buy an ITN by themselves (p = 0.0005). They said that effectiveness of the ITNs was reduced after 6 months and 2–3 times washing. They wished to receive more durable smooth nets with small holes in lace. Misuses of the ITNs such as use the nets for animals and fishing, were also noted.

Conclusion

There should be efforts to improve effective utilization of ITNs by continuous mass free distribution, durability monitoring, surveillance of insecticide resistance of the vector and behaviour change interventions in migrant plantation workers.

Towards making efficient use of household resources for appropriate prevention of malaria: investigating households' ownership, use and expenditures on ITNs and other preventive tools in Southeast Nigeria

BACKGROUND

Many households own, use and spend money on many malaria preventive tools, some of which are inappropriate and ineffective in preventing malaria. This is despite the promotion of use of effective preventive methods such as Insecticide treated nets (ITNs) and indoor residual house spraying (IRHS). The use of these ineffective methods imposes some economic burden on households with no resultant reduction in the risk of developing malaria. Hence, global and national targets in use of various effective malaria preventive toools are yet to be achieved in Nigeria. This paper presents new evidence on the differential use and expenditures on effective and non-effective malaria preventive methods in Nigeria.

METHODS

Semi-structured interviewer administered pre-tested questionnaire were used to collect data from 500 households from two communities in Enugu state, Nigeria. The two study communities were selected randomly while the households were selected systematically. Information was collected on demography, malaria status of children under 5 within the past month, types of malaria preventive tools used by households and how much was spent on these, the per capita household food expenditure and assets ownership of respondents to determine their socio-economic status.

RESULTS

There was high level of ownership of ITNs (73%) and utilization (71.2%), with 40% utilization by children under 5. There were also appreciable high levels of use of other malaria preventive tools such as window and door nets, indoor spray, aerosol spray and cleaning the environment. No significant inequity was found in ownership and utilization of ITNs and in use of other preventive methods across socioeconomic groups. However, households spent a lot of money on other preventive tools and average expenditures were between N0.83-N172 ($0.005-$1.2) The richest households spent the most on window and door nets (P = 0.04).

CONCLUSION

High levels of use and expenditure on ITNs and other malaria preventive tools exist. A programmatic challenge will involve designing ways and means of converting some of the inefficient and inappropriate expenditures on many ineffective malaria preventive tools to proven cost-effective methods such as ITNs and IRHS. This will help to achieve universal coverage with malaria preventive tools.

Insecticide-treated mosquito nets in rural Burkina Faso: assessment of coverage and equity in the wake of a universal distribution campaign

Insecticide-treated mosquito nets (ITNs) are an essential tool of the Roll Back Malaria strategy. An increasing number of African countries have embarked on mass distribution campaigns of long-lasting insecticide-treated nets (LLINs) with the ultimate goal of universal coverage. Such a national campaign with the goal of one ITN for every two people has been conducted in Burkina Faso in 2010. Our aim was to assess the coverage and equity effect of the universal distribution campaign of LLINs in Burkina Faso and to identify determinants of ITN ownership across households after the campaign. We evaluated its effects through comparison of data from two household surveys conducted in early 2010 (before the campaign) and early 2011 (after the campaign) on a representative rural district in north-western Burkina Faso. Data were collected on household characteristics (including socio-economic status) and ITN ownership. We used concentration curves and indices to compare ITN coverage indicators before and after the campaign and multilevel multivariate logistic regression to estimate factors associated with achievement of the universal coverage target in 2011. The survey included 1106 households in 2010 and 1094 in 2011. We found that the proportion of households with at least one ITN increased from 59% before the campaign to 99% afterwards, whereas the concentration index dropped from 0.087 (standard error (SE): 0.014) to 0.002 (SE: 0.002). Fifty-two per cent of households reached the target of one ITN for every two people per household, with the relevant concentration index at -0.031 (SE: 0.016). Eighty-six per cent of households owned at least one ITN for every three people. The main characteristics significantly associated with the targeted intra-household coverage were family size and distance to the health centre but not socio-economic status. In conclusion, despite not having fully met its target, the national LLIN campaign achieved a high level of coverage and fostered equity.

Exploring the impact of targeted distribution of free bed nets on households bed net ownership, socio-economic disparities and childhood malaria infection rates: analysis of national malaria survey data from three sub-Saharan Africa countries

Background

The last decade has witnessed increased funding for malaria control. Malaria experts have used the opportunity to advocate for rollout of such interventions as free bed nets. A free bed net distribution strategy is seen as the quickest way to improve coverage of effective malaria control tools especially among poorest communities. Evidence to support this claim is however, sparse. This study explored the effectiveness of targeted free bed net distribution strategy in achieving equity in terms of ownership and use of bed nets and also reduction of malaria prevalence among children under-five years of age.

Methods

National malaria indicator survey (MIS) data from Angola, Tanzania and Uganda was used in the analysis. Hierarchical multilevel logistic regression models were used to analyse the relationship between variables of interest. Outcome variables were defined as: childhood test-confirmed malaria infections, household ownership of any mosquito net and children’s use of any mosquito nets. Marginal effects of having free bed net distribution on households with different wealth status were calculated.

Results

Angolan children from wealthier households were 6.4 percentage points less likely to be parasitaemic than those in poorest households, whereas those from Tanzania and Uganda were less likely to test malaria positive by 7 and 11.6 percentage points respectively (p < 0.001). The study estimates and present results on the marginal effects based on the impact of free bed net distribution on children's malaria status given their socio-economic background. Poorest households were less likely to own a net by 21.4% in Tanzania, and 2.8% in Uganda, whereas both poorer and wealthier Angolan households almost achieved parity in bed net ownership (p < 0.001). Wealthier households had a higher margin of using nets than poorest people in both Tanzania and Uganda by 11.4% and 3.9% respectively. However, the poorest household in Angola had a 6.1% net use advantage over children in wealthier households (p < 0.001).

Conclusion

This is the first study to use nationally representative data to explore inequalities in bed net ownership and related consequences on childhood malaria infection rates across different countries. While targeted distribution of free bed nets improved overall bed net ownership, it did not overcome ownership inequalities as measured by household socioeconomic status. Use of bed nets was disproportionately lower among poorest children, except for Angola where bed net use was higher among poorest households when compared to children in wealthier households. The study highlights the need for malaria control world governing bodies and policy makers to continue working on finding appropriate strategies to improve access to effective malaria control tools especially by the poorest who often times bears the brunt of malaria burden than their wealthier counterparts.

Higher mosquito production in low-income neighborhoods of Baltimore and Washington, DC: understanding ecological drivers and mosquito-borne disease risk in temperate cities

Mosquito-vectored pathogens are responsible for devastating human diseases and are (re)emerging in many urban environments. Effective mosquito control in urban landscapes relies on improved understanding of the complex interactions between the ecological and social factors that define where mosquito populations can grow. We compared the density of mosquito habitat and pupae production across economically varying neighborhoods in two temperate U.S. cities (Baltimore, MD and Washington, DC). Seven species of mosquito larvae were recorded. The invasive Aedes albopictus was the only species found in all neighborhoods. Culex pipiens, a primary vector of West Nile virus (WNV), was most abundant in Baltimore, which also had more tire habitats. Both Culex and Aedes pupae were more likely to be sampled in neighborhoods categorized as being below median income level in each city and Aedes pupae density was also greater in container habitats found in these lower income neighborhoods. We infer that lower income residents may experience greater exposure to potential disease vectors and Baltimore residents specifically, were at greater risk of exposure to the predominant WNV vector. However, we also found that resident-reported mosquito nuisance was not correlated with our measured risk index, indicating a potentially important mismatch between motivation needed to engage participation in control efforts and the relative importance of control among neighborhoods.

Freely distributed bed-net use among Chano Mille residents, south Ethiopia: a longitudinal study

Background

A huge discrepancy was reported between ownership versus utilization of insecticide-treated bed nets (ITNs). To acquire the benefits of ITNs, households need to use and not merely own them. The objective of this study was to characterize the pattern of, and assess factors related to ITN use in one village in south Ethiopia.

Methods

A prospective cohort study involving 8,121 residents (in 1,388 households) was carried out from April 2009 to April 2011 (101 weeks). Every week, individuals were asked whether they slept under an ITN the night before the interview. Descriptive statistics was used to report the availability and use of ITN. A negative, binomial, probability, distribution model was fitted to find out significant predictors of ITN use. Reasons for not using ITN were summarized.

Results

The total number of ITNs available at the beginning of the study was 1,631 (1.68 ITNs per household). On week 48, 3,099 new ITNs (PermaNet2.0) were distributed freely (2.3 ITNs per household). The number of households who received at least one new ITN was 1,309 (98.4%). The percentage of children <5 years and pregnant women not using ITNs exceeded that of other adults. The mean (range; SD) ITN use fraction before and after mass distribution was 0.20 (0.15-0.27; 0.03) and 0.62 (0.47-0.69; 0.04), respectively. Before mass ITN distribution, the most frequent reason for not using ITN was having worn out bed nets (most complained the bed nets were torn by rats); and after mass ITN distribution, it was lack of convenient space to hang more than one ITN. Males, younger age groups (mainly 15–24 years) and those living away from the vector-breeding site were less likely to use ITN.

Conclusions

The ITN use fraction reached to a maximum of 69% despite near universal coverage (98.4%) was achieved. Gender, age differences and distance from vector breeding site were associated with ITN use. Strategies may need to be designed addressing disproportions in ITN use, lack of convenient space to hang more than one ITN (for those receiving more than one), and measures to prolong usable life of ITNs.

Examining equity in access to long-lasting insecticide nets and artemisinin-based combination therapy in Anambra State, Nigeria

Background

In order to achieve universal health coverage, the government of Anambra State, southeast Nigeria has distributed free Long-lasting Insecticide treated Nets (LLINs) to the general population and delivered free Artemisinin-based Combination Therapy (ACT) to pregnant women and children less than 5 years. However, the levels of coverage with LLINS and ACTs is not clear, especially coverage of different socio-economic status (SES) population groups. This study was carried out to determine the level of coverage and access to LLINs and ACTs amongst different SES groups.

Methods

A questionnaire was used to collect data from randomly selected households in 19 local government areas of the State. Selected households had a pregnant woman and/or a child less than 5 years. The lot quality assurance sampling (LQAS) methodology was used in sampling. The questionnaire explored the availability and utilization of LLINs and ACTs from 2394 households. An asset-based SES index was used to examine the level of access of LLINS and ACTs to different SES quintiles.

Results

It was found that 80.5 % of the households had an LLIN and 64.4 % of the households stated that they actually used the nets the previous night. The findings showed that 42.3 % of pregnant women who had fever within the past month received ACTs, while 37.5 % of children ≪5 years old who had malaria in the past month had received ACTs. There was equity in ownership of nets for the range 1–5 nets per household. No significant SES difference was found in use of ACTs for treatment of malaria in children under five years old and in pregnant women.

Conclusions

The free distribution of LLINs and ACTs increased household coverage of both malaria control interventions and bridged the equity gap in access to them among the most vulnerable groups.

Distance to health services influences insecticide-treated net possession and use among six to 59 month-old children in Malawi

Background

Health ministries and providers are rapidly scaling up insecticide-treated nets (ITN) distribution to control malaria, yet possession and proper use typically remain below targeted levels. In Malawi, health facilities (HFs) are currently the principal points of ITN distribution, making it important to understand how access to these ITN sources affects ownership, possession, and use. The authors evaluated the association between proximity to HFs and ITN possession or use among Malawian children six to 59 months of age.

Methods

A household malaria survey undertaken in eight districts of Malawi during 2007 was used to characterize ITN possession and use. The location of each respondent's household was geocoded as was those of Ministry of Health (MoH) HFs and other health centres. Euclidean distance from each household to the nearest HF was calculated. Patterns of net possession and use were determined through descriptive methods. The authors then analysed the significance of distance and ITN possession/use through standard statistical tests, including logistic regression.

Results

Median distance to HFs was greater among households that did not possess ITNs and did not use an ITN the previous evening. Descriptive statistical methods confirmed a pattern of decreasing ITN possession and use with increasing distance from HFs. Logistic regression showed the same statistically significant association of distance to HFs, even when controlling for age and gender of the child, ratio of nets to children in household, community net possession and use, and household material wealth.

Conclusions

Strategies that exclusively distribute ITNs through HFs are likely to be less effective in increasing possession and use in communities that are more distant from those health services. Health providers should look towards community-based distribution services that take ITNs directly to community members to more effectively scale up ITN possession and regular use aimed at protecting children from malaria.