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

Ideational factors associated with consistent use of insecticide-treated nets: a multi-country, multilevel analysis

BACKGROUND

Malaria remains a major cause of morbidity and mortality in sub-Saharan Africa. Using insecticide-treated nets (ITNs) every night, year-round is critical to maximize protection against malaria. This study describes sociodemographic, psychosocial, and household factors associated with consistent ITN use in Cameroon, Côte d'Ivoire and Sierra Leone.

METHODS

Cross-sectional household surveys employed similar sampling procedures, data collection tools, and methods in three countries. The survey sample was nationally representative in Côte d'Ivoire, representative of the North and Far North regions in Cameroon, and representative of Bo and Port Loko districts in Sierra Leone. Analysis used multilevel logistic regression and sociodemographic, ideational, and household independent variables among households with at least one ITN to identify correlates of consistent ITN use, defined as sleeping under an ITN every night the preceding week.

FINDINGS

Consistent ITN use in Côte d'Ivoire was 65.4%, 72.6% in Cameroon, and 77.1% in Sierra Leone. While several sociodemographic and ideational variables were correlated with consistent ITN use, these varied across countries. Multilevel logistic regression results showed perceived self-efficacy to use ITNs and positive attitudes towards ITN use were variables associated with consistent use in all three countries. The perception of ITN use as a community norm was positively linked with consistent use in Cameroon and Côte d'Ivoire but was not significant in Sierra Leone. Perceived vulnerability to malaria was positively linked with consistent use in Cameroon and Sierra Leone but negatively correlated with the outcome in Côte d'Ivoire. Household net sufficiency was strongly and positively associated with consistent use in all three countries. Finally, the findings revealed strong clustering at the household and enumeration area (EA) levels, suggesting similarities in net use among respondents of the same EA and in the same household.

CONCLUSIONS

There are similarities and differences in the variables associated with consistent ITN use across the three countries and several ideational variables are significant. The findings suggest that a social and behaviour change strategy based on the ideation model is relevant for increasing consistent ITN use and can inform specific strategies for each context. Finally, ensuring household net sufficiency is essential.

Utilization of insecticide treated nets among pregnant women in sodo zuria woreda Southern Ethiopia

Background

The malaria control strategy has shown an improvement in providing services and allocating resources to enhance malaria elimination. The world malaria report indicated that there was a marked increment of insecticide treated net (ITNs) utilization among pregnant women. However, in Ethiopia, the number of households with possession and utilization of ITNs is still far behind the WHO recommendations. Hence, this study was aimed to measure the magnitude of ITN utilization and to identify factors associated with its utilization among pregnant women from April 4, 2021 to April 15, 2021 in Sodo Zuria Woreda, in Wolaita Zone, Southern Ethiopia.

Methods

A community based cross-sectional study was employed. Data were collected using interviewer administered pretested, structured questionnaires. Simple random sampling method was used to select 459 pregnant women. Data were entered into Epi Info version 7 and then exported to statistical package for the social sciences for further analysis. We used time period for data collection of current study. Binary’s logistic regression was used to determine factors affecting insecticides treated net (ITN) utilization. Adjusted Odd Ratios (OR) with 95% CI was used to measures the strengths of associations.

Results

Of 435 surveyed households with pregnant women, 341(78.39%) with 95% Confidence Interval (CI) (74.5%, 82.3%) possessed at least one insecticide treated net. Among them, 194(56.89%) with 95% CI (51.6%, 61.7%) interviewees had self-reported as they slept under insecticide treated net on the night preceding the data collection day. Utilization of insecticide treated nets by other family members, AOR: 6.615(95% CI: 3.358, 13.032), knowledge that the use of insecticide treated nets can prevent malaria, AOR: 3.221(95% CI: 1.737, 5.974), sleeping under insecticide treated nets, AOR: 3.726(95% CI: 1.974, 7.034), and attending ANC follow up visits, AOR: 1.956(95% CI: 1.097), were found to be significantly associated factors with pregnant women’s insecticide treated net utilization.

Conclusion

The number of households with pregnant women who had possession and utilization of ITNs was much lower than the recommendations set by WHO. Therefore, information dissemination to malaria high risk groups about insecticide treated net utilization and replacement of worn-out insecticide treated nets should be emphasized.

Estimating malaria chemoprevention and vector control coverage using program and campaign data: A scoping review of current practices and opportunities

Background

Accurate estimation of intervention coverage is a vital component of malaria program monitoring and evaluation, both for process evaluation (how well program targets are achieved), and impact evaluation (whether intervention coverage had an impact on malaria burden). There is growing interest in maximizing the utility of program data to generate interim estimates of intervention coverage in the periods between large-scale cross-sectional surveys (the gold standard). As such, this study aimed to identify relevant concepts and themes that may guide future optimization of intervention coverage estimation using routinely collected data, or data collected during and following intervention campaigns, with a particular focus on strategies to define the denominator.

Methods

We conducted a scoping review of current practices to estimate malaria intervention coverage for insecticide-treated nets (ITNs); indoor residual spray (IRS); intermittent preventive treatment in pregnancy (IPTp); mass drug administration (MDA); and seasonal malaria chemoprevention (SMC) interventions; case management was excluded. Multiple databases were searched for relevant articles published from January 1, 2015 to June 1, 2018. Additionally, we identified and included other guidance relevant to estimating population denominators, with a focus on innovative techniques.

Results

While program data have the potential to provide intervention coverage data, there are still substantial challenges in selecting appropriate denominators. The review identified a lack of consistency in how coverage was defined and reported for each intervention type, with denominator estimation methods not clearly or consistently reported, and denominator estimates rarely triangulated with other data sources to present the feasible range of denominator values and consequently the range of likely coverage estimates.

Conclusions

Though household survey-based estimates of intervention coverage remain the gold standard, efforts should be made to further standardize practices for generating interim measurements of intervention coverage from program data, and for estimating and reporting population denominators. This includes fully describing any projections or adjustments made to existing census or population data, exploring opportunities to validate available data by comparing with other sources, and explaining how the denominator has been restricted (or not) to reflect exclusion criteria.

Malaria prevalence and long-lasting insecticidal net use in rural western Uganda: results of a cross-sectional survey conducted in an area of highly variable malaria transmission intensity

Background

Long-lasting insecticidal nets (LLINs) remain a cornerstone of malaria control, but strategies to sustain universal coverage and high rates of use are not well-defined. A more complete understanding of context-specific factors, including transmission intensity and access to health facilities, may inform sub-district distribution approaches and tailored messaging campaigns.

Methods

A cross-sectional survey of 2190 households was conducted in a single sub-county of western Uganda that experiences highly variable malaria transmission intensity. The survey was carried out approximately 3 years after the most recent mass distribution campaign. At each household, study staff documented reported LLIN use and source among children 2 to 10 years of age and performed a malaria rapid diagnostic test. Elevation and distance to the nearest health facility was estimated for each household. Associations between parasite prevalence and LLIN use were estimated from log binomial regression models with elevation and distance to clinic being the primary variables of interest.

Results

Overall, 6.8% (148 of 2170) of children age 2–10 years of age had a positive RDT result, yielding a weighted estimate of 5.8% (95% confidence interval [CI] 5.4–6.2%). There was substantial variability in the positivity rates among villages, with the highest elevation villages having lower prevalence than lowest-elevation villages (p < .001). Only 64.7% (95% CI 64.0–65.5%) of children were reported to have slept under a LLIN the previous night. Compared to those living < 1 km from a health centre, households at ≥ 2 km were less likely to report the child sleeping under a LLIN (RR 0.86, 95% CI 0.83–0.89, p < .001). Households located farther from a health centre received a higher proportion of LLINs from government distributions compared to households living closer to health centres.

Conclusions

LLIN use and sourcing was correlated with household elevation and estimated distance to the nearest health facility. The findings suggest that current facility-based distribution strategies are limited in their reach. More frequent mass distribution campaigns and complementary approaches are likely required to maintain universal LLIN coverage and high rates of use among children in rural Uganda.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-021-03835-7.

Coverage outcomes (effects), costs, cost-effectiveness, and equity of two combinations of long-lasting insecticidal net (LLIN) distribution channels in Kenya: a two-arm study under operational conditions

BACKGROUND

Malaria-endemic countries distribute long-lasting insecticidal nets (LLINs) through combined channels with ambitious, universal coverage (UC) targets. Kenya has used eight channels with variable results. To inform national decision-makers, this two-arm study compares coverage (effects), costs, cost-effectiveness, and equity of two combinations of LLIN distribution channels in Kenya.

METHODS

Two combinations of five delivery channels were compared as 'intervention' and 'control' arms. The intervention arm comprised four channels: community health volunteer (CHV), antenatal and child health clinics (ANCC), social marketing (SM) and commercial outlets (CO). The control arm consisted of the intervention arm channels except mass campaign (MC) replaced CHV. Primary analysis used random sample household survey data, service-provider costs, and voucher or LLIN distribution data to compare between-arm effects, costs, cost-effectiveness, and equity. Secondary analyses compared costs and equity by channel.

RESULTS

The multiple distribution channels used in both arms of the study achieved high LLIN ownership and use. The intervention arm had significantly lower reported LLIN use the night before the survey (84·8% [95% CI 83·0-86·4%] versus 89·2% [95% CI 87·8-90·5%], p < 0·0001), higher unit costs ($10·56 versus $7·17), was less cost-effective ($86·44, 95% range $75·77-$102·77 versus $69·20, 95% range $63·66-$77·23) and more inequitable (Concentration index [C.Ind] = 0·076 [95% CI 0·057 to 0·095 versus C.Ind = 0.049 [95% CI 0·030 to 0·067]) than the control arm. Unit cost per LLIN distributed was lowest for MC ($3·10) followed by CHV ($10·81) with both channels being moderately inequitable in favour of least-poor households.

CONCLUSION

In line with best practices, the multiple distribution channel model achieved high LLIN ownership and use in this Kenyan study setting. The control-arm combination, which included MC, was the most cost-effective way to increase UC at household level. Mass campaigns, combined with continuous distribution channels, are an effective and cost-effective way to achieve UC in Kenya. The findings are relevant to other countries and donors seeking to optimise LLIN distribution.

TRIAL REGISTRATION

The assignment of the intervention was not at the discretion of the investigators; therefore, this study did not require registration.

A Mass Insecticide-Treated Bed Net Distribution Campaign Reduced Malaria Risk on an Individual but Not Population Level in a Highland Epidemic-Prone Area of Kenya

In epidemic-prone areas of the western highlands, the Kenya Ministry of Health conducted campaigns of indoor residual spraying (IRS) of households, followed by mass distribution of insecticide-treated bed nets (ITNs), as part of the National Malaria Strategy. We previously reported that in the highland areas of Kipsamoite and Kapsisiywa, widespread IRS coverage in 2007, after lower but substantial coverage in 2005 and 2006, contributed to possible local interruption of malaria transmission between 2007 and 2008. Indoor residual spraying campaigns in the area ended in 2010, succeeded by a mass ITN distribution campaign in 2011 and 2012 targeting universal coverage. Insecticide-treated bed net use in the area increased from 17.1% pre-campaign in 2011 to 51.7% post-campaign in 2012, but decreased to 35.8% in 2013. The ITN campaign did not reduce malaria incidence in the population as a whole (odds ratio [OR] after ITN distribution versus before, 1.29, 95% CI: 1.00-1.66, P = 0.049). However, in 2011-2013, individuals who stated that they slept under ITNs as compared with those who did not had a decrease in malaria incidence that approached statistical significance (OR 0.74, 95% CI: 0.52-1.04, P = 0.08). Mass ITN distribution after previous annual IRS campaigns was insufficient to further reduce malaria transmission in this area of low and highly seasonal transmission possibly because of low ITN use despite the mass campaign.

Long-lasting insecticidal nets retain bio-efficacy after 5 years of storage: implications for malaria control programmes

Background

Long-lasting insecticidal nets (LLINs) are the most sustainable and effective malaria control tool currently available. Global targets are for 80% of the population living in malaria endemic areas to have access to (own) and use a LLIN. However, current access to LLINs in endemic areas is 56% due to system inefficiencies and budget limitations. Thus, cost-effective approaches to maximize access to effective LLINs in endemic areas are required. This study evaluated whether LLINs that had been stored for 5 years under manufacturer’s recommended conditions may be optimally effective against Anopheles mosquitoes, to inform malaria control programmes and governments on the periods over which LLINs may be stored between distributions, in an effort to maximize use of available LLINs.

Methods

Standard World Health Organization (WHO) bioassays (cone and tunnel test) were used to evaluate the bio-efficacy and wash resistance of Olyset^® and DawaPlus^® 2.0 (rebranded Tsara^® Soft) LLINs after 5 years of storage at 25 °C to 33.4 °C and 40% to 100% relative humidity. In addition, a small scale Ifakara Ambient Chamber test (I-ACT) was conducted to compare the bio-efficacy of one long stored LLINs to one new LLIN of the same brand, washed or unwashed. LLINs were evaluated using laboratory reared fully susceptible Anopheles gambiae sensu stricto (s.s.) (Ifakara strain) and pyrethroid resistant Anopheles arabiensis (Kingani strain).

Results

After 5 years of storage, both unwashed and washed, Olyset^® and DawaPlus^® 2.0 (Tsara^® Soft) LLINs passed WHO bio-efficacy criteria on knockdown (KD60) ≥ 95%, 24-h mortality ≥ 80% and ≥ 90% blood-feeding inhibition in WHO assays against susceptible An. gambiae s.s. DawaPlus^® 2.0 LLINs also passed combined WHO bioassay criteria against resistant An. arabiensis. Confirmatory I-ACT tests using whole nets demonstrated that long-stored LLINs showed higher efficacy than new LLINs on both feeding inhibition and mortality endpoints against resistant strains.

Conclusions

Even after long-term storage of around 5 years, both Olyset^® and DawaPlus^® 2.0 LLINs remain efficacious against susceptible Anopheles mosquitoes at optimal storage range of 25 °C to 33.4 °C for temperature and 40% to 100% relative humidity measured by standard WHO methods. DawaPlus^® 2.0 (Tsara^® Soft) remained efficacious against resistant strain.

Costs of insecticide-treated bed net distribution systems in sub-Saharan Africa

Background

Insecticide-treated nets (ITNs) are one of the most cost-effective measures for preventing malaria. The World Health Organization recommends both large-scale mass distribution campaigns and continuous distributions (CD) as part of a multifaceted strategy to achieve and sustain universal access to ITNs. A combination of these strategies has been effective for scaling up ITN access. For policy makers to make informed decisions on how to efficiently implement CD or combined strategies, information on the costs and cost-effectiveness of these delivery systems is necessary, but relatively few published studies of the cost continuous distribution systems exist.

Methods

To address the gap in continuous distribution cost data, four types of delivery systems—CD through antenatal care services (ANC) and the expanded programme on immunization (EPI) (Ghana, Mali, and mainland Tanzania), CD through schools (Ghana and mainland Tanzania), and a combined community/health facility-based distribution (Zanzibar, Tanzania), as well as mass distributions (Mali)—were costed. Data on costs were collected retrospectively from financial and operational records, stakeholder interviews, and resource use surveys.

Results

Overall, from a full provider perspective, mass distributions and continuous systems delivered ITNs at overlapping economic costs per net distributed (mass distributions: 4.37–4.61 USD, CD channels: 3.56–9.90 USD), with two of the school-based systems and the mass distributions at the lower end of this range. From the perspective of international donors, the costs of the CD systems were, for the most part, less costly than the mass distributions (mass distributions: 4.34–4.55 USD, Ghana and Tanzania 2017 school-based: 3.30–3.69 USD, health facility-based: 3.90–4.55 USD, combined community/health facility 4.55 USD). The 2015 school-based distribution (7.30 USD) and 2016 health facility-based distribution (6.52 USD) programmes in Tanzania were an exception. Mass distributions were more heavily financed by donors, while CD relied more extensively on domestic resource contributions.

Conclusions

These results suggest that CD strategies can continue to deliver nets at a comparable cost to mass distributions, especially from the perspective of the donor.

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.

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

Background

The degree to which insecticide-treated net (ITN) supply accounts for age and gender disparities in ITN use among household members is unknown. This study explores the role of household ITN supply in the variation in ITN use among household members in sub-Saharan Africa.

Methods

Data was from Malaria Indicator Surveys or Demographic and Health Surveys collected between 2011 and 2016 from 29 countries in sub-Saharan Africa. The main outcome was ITN use the previous night. Other key variables included ITN supply (nets/household members), age and gender of household members. Analytical methods included logistic regressions and meta-regression.

Results

Across countries, the median (range) of the percentage of households with enough ITNs was 30.7% (8.5–62.0%). Crude analysis showed a sinusoidal pattern in ITN use across age groups of household members, peaking at 0–4 years and again around 30–40 years and dipping among people between 5–14 and 50+ years. This sinusoidal pattern was more pronounced in households with not enough ITNs compared to those with enough ITNs. ITN use tended to be higher in females than males in households with not enough ITNs while use was comparable among females and males in households with enough ITNs. After adjusting for wealth quintile, residence and region, among households with not enough ITNs in all countries, the odds of ITN use were consistently higher among children under 5 years and non-pregnant women 15–49 years. Meta-regressions showed that across all countries, the mean adjusted odds ratio (aOR) of ITN use among children under 5 years, pregnant and non-pregnant women aged 15–49 years and people 50 years and above was significantly higher than among men aged 15–49 years. Among these household members, the relationship was attenuated when there were enough ITNs in the household (dropping 0.26–0.59 points) after adjusting for geographical zone, household ITN supply, population ITN access, and ITN use:access ratio. There was no significant difference in mean aOR of ITN use among school-aged children compared to men aged 15–49 years, regardless of household ITN supply.

Conclusions

This study demonstrated that having enough ITNs in the household increases level of use and decreases existing disparities between age and gender groups. ITN distribution via mass campaigns and continuous distribution channels should be enhanced as needed to ensure that households have enough ITNs for all members, including men and school-aged children.

Design, Implementation, and Evaluation of a School Insecticide-Treated Net Distribution Program in Cross River State, Nigeria

BACKGROUND

In 2013, the World Health Organization recommended distribution through schools, health facilities, community health workers, and mass campaigns to maintain coverage with insecticide-treated nets (ITNs). We piloted school distribution in 3 local government areas (LGAs) of Cross River State, Nigeria.

METHODS

From January to March 2011, all 3 study sites participated in a mass ITN campaign. Baseline data were collected in June 2012 (N=753 households) and school distribution began afterward. One ITN per student was distributed to 4 grades once a year in public schools. Obubra LGA distributed ITNs in 2012, 2013, and 2014 and Ogoja LGA in 2013 and 2014 while Ikom LGA served as a comparison site. Pregnant women in all sites were eligible to receive ITNs through standard antenatal care (ANC). Endline survey data (N=1,450 households) were collected in March 2014. Data on ITN ownership, population access to an ITN, and ITN use were gathered and analyzed. Statistical analysis used contingency tables and chi-squared tests for univariate analysis, and a concentration index was calculated to assess equity in ITN ownership.

RESULTS

Between baseline and endline, household ownership of at least 1 ITN increased in the intervention sites, from 50% (95% confidence interval [CI]: 44.7, 54.3) to 76% (95% CI: 71.2, 81.0) in Ogoja and from 51% (95% CI: 35.3, 66.7) to 78% (95% CI: 71.5, 83.1) in Obubra, as did population access to ITN, from 36% (95% CI: 32.0, 39.5) to 53% (95% CI: 48.0, 58.0) in Ogoja and from 34% (95% CI: 23.2, 45.6) to 55% in Obubra (95% CI: 48.4, 60.9). In contrast, ITN ownership declined in the comparison site, from 64% (95% CI: 56.4, 70.8) to 43% (95% CI: 37.4, 49.4), as did population ITN access, from 47% (95% CI: 40.0, 53.7) to 26% (95% CI: 21.9, 29.9). Ownership of school ITNs was nearly as equitable (concentration index 0.06 [95% CI: 0.02, 0.11]) as for campaign ITNs (-0.03 [95% CI: -0.08, 0.02]), and there was no significant oversupply or undersupply among households with ITNs. Schools were the most common source of ITNs at endline and very few households (<2%) had nets from both school and ANC.

CONCLUSION

ITN distribution through schools and ANC provide complementary reach and can play an effective role in achieving and maintaining universal coverage. More research is needed to evaluate the cost-effectiveness of such continuous distribution channels in combination with, or as a potential replacement for, subsequent mass campaigns.

Impact of a 15-month multi-channel continuous distribution pilot on ITN ownership and access in Eastern Region, Ghana

Background

Insecticide-treated nets are a key intervention for malaria prevention. While mass distribution can rapidly scale up ITN coverage, multiple channels may be needed to sustain high levels of ITN access and ownership. In Ghana’s Eastern Region, a continuous ITN distribution pilot, started in October 2012, 18–24 months after a mass campaign. The pilot distributed ITNs through antenatal care services (ANC), child welfare clinic services (CWC) through the Expanded Programme on Immunization, and to students in two classes of primary schools.

Methods

ITN ownership and access were evaluated through two cross-sectional surveys, conducted at baseline in April 2012, 11–15 months after the mass campaign, and at endline in December 2013, after 1 year of continuous distribution. A representative sample was obtained using a multi-stage cluster sampling design. Household heads were interviewed using a structured questionnaire.

Results

Household ownership of at least one ITN was 91.3% (95% CI 88.8–93.9) at baseline and was not statistically significant at endline 18 months later at 88.3% (95% CI 84.9–91.0) (p = 0.10). Ownership of at least 1 ITN per two people significantly decreased from 51.3% (95% CI 47.1–55.4) to 40.2% (95% CI 36.4–44.6) (p < 0.01). Population access to an ITN within the household also significantly decreased from 74.5% (95% CI 71.2–77.7) at baseline to 66.4% (95% CI 62.9–69.9) at endline (p < 0.01). The concentration index score for any CD channel was slightly positive (0.10; 95% CI 0.04–0.15).

Conclusion

Thirty-one months after the mass campaign, the 15 months of continuous distribution activities had maintained levels of household ownership at least one ITN, but household ownership of one ITN for every two people and population access to ITN had declined. Ownership and access were higher with the CD programme than without. However, the number of ITNs delivered via ANC, CWC and two primary school classes were insufficient to sustain coverage targets. Future programmes should implement continuous distribution strategies fully within 1 year after a campaign or widen eligibility criteria (such as increase the number of classes) during the first year of implementation to make up for programme delays.

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.