FOUR ON MALARIA BEDNETS
| Wednesday, 25th of May 2011 |
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BEDNETS I: WHICH NETS ARE BEING USED
‘[M]ore education about use and care of nets; making nets more resistant to damage; and encouraging net mending are likely to maximize the huge investment in scale up of net ownership by ensuring they are used. Without this step, the widespread benefits of LLIN cannot be realized.’
Full text, with figures, is at
http://www.malariajournal.com/content/pdf/1475-2875-10-92.pdf
Malaria Journal 2011, 10:92doi:10.1186/1475-2875-10-92
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Published: |
17 April 2011 |
Abstract (provisional)
Background
There has been recent large scale-up of malaria control interventions in Ethiopia where transmission is unstable. While household ownership of long-lasting insecticidal nets (LLIN) has increased greatly, there are concerns about inadequate net use. This study aimed to investigate factors associated with net use at two time points, before and after mass distribution of nets.
Methods
Two cross sectional surveys were carried out in 2006 and 2007 in Amhara, Oromia and SNNP regions. The latter was a sub-sample of the national Malaria Indicator Survey (MIS 3R). Each survey wave used multi-stage cluster random sampling with 25 households per cluster (224 clusters with 5,730 households in Baseline 2006 and 245 clusters with 5,910 households in MIS 3R 2007). Net ownership was assessed by visual inspection while net utilization was reported as use of the net the previous night. This net level analysis was restricted to households owning at least one net of any type. Logistic regression models of association between net use and explanatory variables including net type, age, condition, cost and other household characteristics were undertaken using generalized linear latent and mixed models (GLLAMM).
Results
A total of 3,784 nets in 2,430 households were included in the baseline 2006 analysis while the MIS 3R 2007 analysis comprised 5,413 nets in 3,328 households. The proportion of nets used the previous night decreased from 85.1% to 56.0% between baseline 2006 and MIS 3R 2007, respectively. Factors independently associated with increased proportion of nets used were: LLIN net type (at baseline 2006); indoor residual spraying (at MIS 3R 2007); and increasing wealth index at both surveys. At both baseline 2006 and MIS 3R 2007, reduced proportion of nets used was independently associated with increasing net age, increasing damage of nets, increasing household net density, and increasing altitude (>2,000m).
Conclusion
This study identified modifiable factors affecting use of nets that were consistent across both surveys. While net replacement remains important, the findings suggest that: more education about use and care of nets; making nets more resistant to damage; and encouraging net mending are likely to maximize the huge investment in scale up of net ownership by ensuring they are used. Without this step, the widespread benefits of LLIN cannot be realized.
BEDNETS II:
Reported reasons for not using a mosquito net when one is available: a review of the published literature
Justin Pulford1,2 , Manuel W Hetzel1,2 , Miranda Bryant3 , Peter M Siba1 and Ivo Mueller4
1 Papua New Guinea Institute of Medical Research (PNGIMR), PO Box 60, Goroka, EHP 441, Papua New Guinea
2 School of Population Health, University of Queensland, Brisbane, Australia
3 Population Services International (PSI), Papua New Guinea
4 Barcelona Centre for International Health Research, Barcelona, Spain
author email corresponding author email
Malaria Journal 2011, 10:83doi:10.1186/1475-2875-10-83
The electronic version of this article is the complete one and can be found online at: http://www.malariajournal.com/content/10/1/83
© 2011 Pulford et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
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.
Background
Mosquito nets, most commonly in the form of insecticide-treated mosquito nets (ITN), are a central component of current global malaria control initiatives. The evidence in support of ITNs as a malaria control strategy is overwhelming. Systematic reviews of randomized controlled trials confirm a significant reduction in individual risk of malaria-related morbidity and mortality associated with ITN use [1,2]. Individuals' not sleeping under an ITN, but living within an area with high ITN coverage, have also been shown to be at decreased risk of infection due to the resulting reduction in overall malaria transmission [3,4]. Encouragingly then, and largely as a result of donor-funded distribution programmes, ITN ownership has substantially increased in many malaria-endemic countries over the past decade [5-8].
Mosquito net ownership is far from universal despite the aforementioned gains. Ownership rates remain low in many malarious regions or amongst particular groups in malarious regions [9-12]. Furthermore, mosquito net ownership in itself is not synonymous with utilization. For example, in one study in Niger, West Africa, as few as 33% of available mosquito nets in mosquito net owning households were used the night prior to survey [13]. The rate of mosquito net use in these ITN owning households was substantially less than 100% indicating factors other than availability were responsible for reported instances of mosquito net non-use. Other studies, again in contexts where fewer than 100% of household members reported mosquito net use, have reported between 15-50% of available nets going unused [14-17]. Thus, ownership is not the only obstacle to achieving the reductions in malaria morbidity and mortality associated with ITN use; rather, individuals who own (or who have available) mosquito nets must use them in order for the potential health impact to be fully realized.
Determining whether sub-optimal mosquito net utilization in a given population is due to a lack of availability or a failure to utilize available nets is operationally important in a malaria control context as it would inform the subsequent response [11]. This 'targeted' approach to mosquito net promotion is encapsulated in a recently proposed framework designed to inform "...evidence-based and country-specific strategies to increase population coverage with ITNs and work towards the interruption of malaria transmission" [18]. Three categories of mosquito net non-use are recognized within this framework: 1) living in households with no mosquito nets present; 2) living in households owning, but not hanging a mosquito net; and 3) living in households that have a mosquito net hanging but who are not sleeping under a mosquito net. Depending on which category is found to account for most or significant mosquito net non-use, the authors argue resulting interventions should variously focus on improving mosquito net availability (category 1), encouraging the hanging of mosquito nets (category 2), or targeting individuals to encourage use of an existing mosquito net (category 3) [18].
This framework usefully highlights the variability in reasons for mosquito net non-use and the importance of tailoring intervention strategies accordingly; however, the necessary interventions to promote greater mosquito net use among mosquito net 'owners' (category 2 and 3) are likely to be considerably more complex than the 'information, education or behaviour change communication' campaigns subsequently suggested [18]. For example, mosquito net non-use among mosquito net owning individuals has been variously attributed to practical barriers associated with erecting a mosquito net [19], the temporary unavailability of a normally available mosquito net [20] or a range of social factors that render mosquito net use impractical in the short-term [21]. An educational- or behaviour change-based intervention designed to promote greater mosquito net use is unlikely to be effective in these cases (in isolation, at least); rather, design modifications at the manufacturer level, the provision of additional mosquito nets or the promotion of complementary malaria control interventions may be better considered.
A review of the barriers to mosquito net use has yet to be presented in the published literature despite considerable research interest in this area. The aim of this paper, therefore, was to partly address 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 individuals who have one available. It was anticipated that a focused review of this nature would highlight the current state of the literature pertaining to a specific population of mosquito net non-users and, pending the quality and scope of the available evidence, potentially inform an intervention or range of interventions best suited to promoting greater net use amongst this group.
Method
Search strategy
Studies were sought via a search of the Medline database. The reference period for the search was January 1990 to September 2010. The search was limited to English language publications and was conducted using the following keywords: mosquito net, bed net, ITN, LLIN and barrier, non use, reason, sleep, attitude, knowledge, practice, misuse, obstacle, perception, acceptability, reaction, belief. Further studies were also sought via a manual search of references listed in retrieved articles.
Study selection
Studies were included in this review if they presented reasons for not using a mosquito net from an individual or individuals who were reported to own/have available a mosquito net. The key inclusion criteria were, therefore, that study participants could be identified as owning a mosquito net or having a mosquito net available to 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. Studies were excluded from review if the reported reasons for not using a mosquito net could not be attributed to a known mosquito net owner or if the same data were reported in another (included) publication. For convenience, individuals' who own a mosquito net or who have a mosquito net available for use are referred to as mosquito net 'owners' in the following review.
Results
Publications presenting relevant data obtained from two broad types of study design were identified by the search criteria: namely, publications presenting data obtained in response to a structured survey question and publications presenting data obtained in response to some form of qualitative enquiry. The respective survey- and qualitative- data are reviewed separately below.
Survey data
A total of 17 studies meeting the inclusion/exclusion criteria were identified in which reasons for not using a mosquito net, as reported by identified mosquito net owners (or the caregivers/household heads on behalf of mosquito net owners) in response to a structured survey question(s), were described. In eight of these 17 studies the proportion of respondents reporting each of the respective reasons for not using a mosquito net was not identified or the proportion was identified, but no denominator was provided or could be calculated [13,19,22-27]. These studies (non-specific) are reviewed separately from the remaining nine studies in which detailed 'reasons for not using a mosquito net' data were presented (specific).
The nine 'specific' studies are listed in Table 1 along with the respective study population, sample size, net type, non-use measure, the reported reasons for non-use, and the reported number of participants endorsing each of the listed reasons. For better comparability each reported reason was assigned to one of six 'reason for non-use' categories based in part on those reported in Alaii et al [20]. The assigned categories - availability (non-use due to the unavailability of a normally available net), discomfort (non-use due to personal discomfort), perceived (low) mosquito density (non-use due to a perceived low mosquito density), social (non-use due to factors associated with the individuals social environment), technical (non-use due to technical issues associated with hanging or using a net), and other (reasons for non-use that do not fall into the aforementioned categories) - are also presented in Table 1.
Table 1. Reported reasons for non-use as given by participants who own/have available a mosquito net
The reported reasons for not using a mosquito net were seemingly obtained by open-ended questioning in all nine studies, although this was only overtly stated in two [20,28]. More than one response per participant was reported in three studies [20,28,29]; in the remaining studies one or less response per participant was reported, although it was not always clear whether single or multiple responses per participant were permissible (i.e. some participants may have reported multiple reasons whilst others reported none). Four of the reported surveys were conducted during a period of peak malaria transmission [30-33], three were conducted at multiple time points across seasons [20,21,28], one in a low transmission period [29] and in one study the reference period (use during pregnancy) spanned multiple seasons, although the timing of the survey was unclear [34]. Mosquito-net non-use was independently corroborated in two studies [20,31] and was based on self-report in the others. With respect to geographic location, one study was conducted in the Solomon Islands [33], one in India [32], whilst the remaining studies were conducted in sub-Saharan Africa.
As can be seen from Table 1, six of the nine studies presented reason for not using a mosquito net data obtained from (or on behalf of) a specific sub-population [20,28-30,33,34]. Two studies presented data obtained from (or on behalf of) all household members [21,31], and one presented data obtained from adult household members only [32]. Sample sizes ranged from 17 to 294 across the nine studies, although were particularly low (< 30) in three cases [29-31]. Five studies provided a measure of mosquito net non-use that was inclusive of a time period; namely, non-use the night [28,30,31] or week [21] immediately prior to the respective survey or during the course of pregnancy [34]. In the remaining studies the non-use measure was defined (use of mosquito net < seven nights a week), but not period specific [29,32] or was not defined at all [20,33]. Five of the studies presented data pertaining to ITN that required regular insecticide re-treatment [20,21,30,33,34]; long lasting insecticide treated mosquito nets (LLIN) were the norm in the four other studies.
The predominant reasons for not using a mosquito net varied across studies, as did the number and range. Nevertheless, discomfort (primarily heat) was the predominant reason for non-use in four out of the nine studies and discomfort and perceived mosquito density were cited as reasons for non-use (although not necessarily the predominant reason) in seven out of nine and six out of nine studies, respectively. Pooling the data from across the nine studies, 948 participants reported 697 reasons for not using a mosquito net. Of these 697 reported reasons, 47.5% (331/697) pertained to discomfort, 20.1% (140/697) to social factors, 12.3% (86/697) to perceived mosquito density, 5.2% (36/697) to technical factors, 2.9% (20/697) to mosquito net availability, and 12.1% (84/697) to various 'other' factors three quarters of which specifically related to misinformation (being told not to use a provided mosquito net until after the child was born) or the onset of child birth ('experiencing labour pains'). Discomfort was the most common reason for non-use cited, irrespective of whether the net type was ITN or LLIN.
Findings from the eight 'non-specific' studies, whilst difficult to quantify or generalize, were largely consistent with those described above. Perceived mosquito density and heat (discomfort) were identified as the primary reasons for not using a mosquito net the night prior to the survey among an indeterminate number of pregnant women by Njoroge et al [25]. Similarly, Binka and Adongo [24] reported perceived mosquito density and heat as the reasons why 80% of 875 respondents did not use mosquito nets during the dry season (as compared to 0.3% during the rainy season). Klein et al [27] reported that one-third of the surveyed respondents (female household heads) from mosquito net owning homes (73% of 260) "indicated that they did not use them regularly because of the heat" (p. 385). Perceived mosquito density and low disease incidence were the reported reasons for not using a net in the 43 households in which a net was owned, but not used, in Hlongwana et al [22]. In Thwing et al [13], 68.1% of an indeterminate number of the nets reported as not hanging during the dry season "were not hanging because the respondents believed there were no mosquitoes" (p. 831). This figure fell to 6.1% during the wet season. Thwing et al [13] also report that, during both the wet and dry seasons, < 5% of nets not hanging were reportedly unused because of an inability to hang them. Heat along with other discomfort factors of smell and constraint were reported as the reasons why an indeterminate proportion of 471 survey respondents did not use their mosquito nets 'regularly' by Agyepong & Manderson [26].
Heat was identified as a factor contributing to partial mosquito net use (use for part of the night, but not all) by Frey et al [23]. In this study, the mothers of 21 children identified as having only slept under a mosquito net for part of the night prior to the survey, reported sleeping the first part of the night (with their child) outside of the house (and away from the mounted mosquito net) due to high inside temperatures. Prolonged household activity in which the child was carried on the back of his or her mother was also identified as another reason for partial mosquito net use by children in the Frey et al [23] study. The only 'non-specific' study in which heat or perceived mosquito density were not reported as reasons for not using a mosquito net was the Das et al [19] study of mosquito net texture preference. In this study, in which 60 household members were given two types of mosquito nets to trial over a 14 day period, reported reasons for not using the nets included leaking of rainwater from roof (technical), no material to tie the net (technical), use of the mosquito net by someone else (availability), or spending the night elsewhere (social).
Qualitative data
Multiple studies were identified in which reasons for mosquito net non-use, obtained via qualitative enquiry, were presented as part of a larger body of findings. However, participants in most of these studies were not selected on the basis of being identified mosquito net owners and it was unclear, therefore, as to whether the reported reasons for non-use were based on personal experience or conjecture. Accordingly, studies in which it was not possible to distinguish the responses of mosquito net owners from non-owners were excluded from review. A total of four studies were identified in which data pertaining to mosquito net non-use, obtained via in-depth interview or focus group discussion (FGD) with mosquito net owners, were presented [35-38]. The relevant data in all four of these studies were a minor component of the reported findings and the identified mosquito net owning participants were a (identifiable) sub-sample of the respective participant groups. Nevertheless, the findings remain of interest given the review topic and are summarized below.
Alaii et al [35] interviewed 12 mothers from homes that had purchased their own mosquito net as part of a pre-intervention study in Western Kenya. Participants reported using the mosquito nets in the cold/rainy season and then stopping at perceived times of low mosquito density. Heat (discomfort) was most often cited as a 'problem' with mosquito nets as were 'technical' issues associated with washing or deploying the net, the size of the net (too small), and nets 'trapping' small children left unattended in bed. Atkinson et al [36] examined the acceptability and participant preference of three types of mosquito net via 12 FGDs in the Solomon Islands. Intermittent mosquito net use was described by 'most' participants from areas of low or seasonal mosquito nuisance. Amongst these participants mosquito net use was reportedly highest during times of perceived high mosquito density, the cooler months of the year or when a family member was sick with malaria. Howard et al [37] conducted six FGDs and 14 in-depth interviews with male (5 & 8, respectively) or female (1 & 6, respectively) ITN-owners living in eastern Afghanistan under the Taliban regime. Consistent with Alaii et al [35] and Atkinson et al [36], many participants reported only using the ITNs in summer when perceived mosquito densities were highest, even though a number were aware that malaria could be transmitted in other seasons. Other reasons for non-use, not related to availability, were not reported. Finally, Toe et al [38] interviewed 50 mosquito net users and 50 non-users as part of an LLIN acceptability study in Burkina Faso, Africa. Participants reported that they did not use their nets when they were not bothered by mosquitoes, even during periods of high malaria transmission. Low motivation for mosquito net use was evident with participants using damaged nets that could easily be repaired or replaced or reportedly forgetting to use mosquito nets. On the basis of the participant response, Toe et al [38] concluded that the mosquito net was primarily used to combat mosquito nuisance when necessary, rather than as a form of malaria control.
A further study was identified in which the reasons why an individual mosquito net (as opposed to mosquito net owner) was not used were examined by a mixed methodology. This study presented findings from an investigation of factors associated with the use and non-use of mosquito nets in two Ethiopian states [16]. The qualitative component of this study was integrated into a structured survey instrument and involved the use of open-ended questioning. Specifically, when a household included in the survey sample "...had an ITN that had not been slept under the prior night, the interviewer asked why, and was allowed to probe for clarification and ask follow-up questions" [16]. Resulting responses were obtained from the male or female household head and were hand recorded. Analysis of the qualitative data was not described in detail, although appeared limited to a summary of open-ended responses by an unreported method. The study took place during a period of high malaria transmission.
The survey identified a total of 1,405 ITNs owned across 857 households. Of the ITNs owned, 65% were reportedly used the night prior to the survey leaving a total of 492 unused nets. Thus, open-ended question data were presumably obtained on the reasons why these 492 nets were unused (sample size was not reported in the respective study). Seven primary reasons for mosquito net non-use emerged from the analysis of these data. Three of these reasons were consistent with the findings from the survey data reviewed above; namely, the perception that malaria or mosquitoes were not a serious problem (risk perception), the difficulty of hanging ITNs in traditional houses (technical), and the saving of ITNs for future use (other).
The four remaining themes to emerge were less evident in the survey data reviewed above, possibly reflective of the focus on whether an identified mosquito net had been used as opposed to whether an individual had used a mosquito net or not. These themes included the net being used for a purpose other than that for which it was intended, e.g. as a table cloth or room divider, the net being unused due to its poor condition, and misinformation or lack of information, especially with respect to whether the ITNs could be washed or whether they required retreatment (although, arguably, this reflects less a reason for not using a mosquito net and more confusion as to how the mosquito net should be cared for). The final theme, and the single most widely reported reason for not using a mosquito net in this study, was a perceived loss in ITN effectiveness based on the observation that dead insects no longer gathered around the net or on the belief that the ITN needed retreatment. This latter theme along with reports that mosquito nets are not being used due to their poor condition suggest that many households may be maintaining mosquito nets considered past their 'used by' date. This finding may, therefore, highlight a need to distinguish between the ownership of 'active' versus 'expired' mosquito nets in studies of this type.
Discussion and Conclusion
Discomfort, primarily due to heat, was the most widely identified reason why mosquito net owners chose not to use a mosquito net on one or more nights in the 17 survey-based studies included in this review. The next most widely reported reason for not using a mosquito net in the survey-based studies was perceived low mosquito density; although this only accounted for 12.3% of all responses in the pooled data set (compared to 47.5% for discomfort) suggesting it was widely reported, but often at a relatively low frequency. Heat and perceived mosquito density were also consistently identified in the small number of studies presenting qualitative data, although perceived mosquito density more clearly emerged as the dominant reason for not using a mosquito net in these studies. In one qualitative study participants reported that the primary function of mosquito nets was to combat perceived mosquito nuisance (i.e. disruption of sleep) rather than malaria transmission [38]. This finding has been reported elsewhere [24,27] and indicates that the practical function of mosquito nets may differ from the intended function in some instances. The reported use of mosquito nets for fishing would be an extreme example of a problematic discrepancy between intended and practical mosquito net function [39]. Utilizing a mosquito net to minimize sleep disturbance rather than malaria transmission is considerably less problematic as protection against malaria transmission is still conferred when the net is in use. Indeed, social marketing campaigns have even promoted ITNs as a means to minimize sleep disturbance [40]. However, if this discrepancy results in seasonal or irregular use (as the evidence presented in this review indicates) then the benefit of mosquito net utilization may not be fully realized. If a primary motivation to use a mosquito net is perceived mosquito density, then it also stands to reason that in areas where mosquito density falls as a result of increased ITN coverage the continued motivation to use an ITN may decrease. In other words, the very effectiveness of the ITN may render further ITN use undesirable. If such a scenario were to eventuate, then any programmatic gains in terms of reduced malaria-related morbidity and mortality, as well as the possibility of future malaria elimination, could be potentially threatened. The relationship between mosquito net use and mosquito density may, therefore, warrant careful and ongoing investigation in areas experiencing an increase in ITN coverage.
If personal discomfort and, to a lesser extent, perceived mosquito density are the primary reasons for not using a mosquito net amongst mosquito net owners, then greater mosquito net use could potentially be achieved amongst this population via education or behaviour change communication (BCC) strategies as previously suggested [11,18]. With respect to personal discomfort, however, education or BCC strategies would do nothing to change the physical properties of the mosquito net that cause the discomfort in the first place. Thus, modifications to mosquito nets or the mosquito net using environment that render the mosquito net more comfortable would usefully complement any educational or BCC campaign.
This review identified other reasons for not using a mosquito net that may also be better addressed via strategies other than (or in addition to) education or BCC. The pooled survey data indicated that social factors, such as sleeping elsewhere, or not sleeping at all, frequently result in mosquito net non-use. 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 mosquito net (primarily due to someone else using it) were also reported in the survey and qualitative studies. Social obstacles to mosquito net use may be addressed by complementary mosquito control strategies. For example, if someone is active (i.e. not in bed) during night time hours then insect repellents could be made available and their use promoted; a malaria control strategy previously trialled with some success [41,42]. Alternatively, if an individual is required to sleep somewhere other than their normal residence then additional 'travel' mosquito nets could be made available.
Additional mosquito nets in the house would usefully address the issue of non-use due to the temporary unavailability of a normally available net. Individuals who spend part of the night sleeping outdoors and part of the night sleeping indoors, a reason for 'partial' non-use identified in this review [23] and reported elsewhere [43], may also benefit from additional mosquito nets if they were able to hang them in their various sleeping areas. Nevertheless, hanging mosquito nets outdoors may continue to be problematic given current mosquito net designs and their reliance on external supporting structures. Thus, the development of 'outdoor' or 'stand alone' mosquito nets that require no external supports yet remain portable and user friendly would be beneficial. Increasing mosquito net use via a reduction in the technical difficulties associated with hanging or using a net may also best be achieved at the manufacturer level. Innovative design solutions could potentially resolve the reported difficulties in hanging a net in certain household structures (e.g. via the incorporation of internal or complementary supporting structures, compact sizes, or alternative 'clamping/tying' systems) or increase the ease with which a net may be utilized once hung. Where technical issues remain problematic consideration could even be given to the promotion of LLIN hammocks, blankets or curtains or even insecticide treated plastic sheeting (as a wall covering).
Perhaps the most important finding of this review pertains to the current state of the published research literature, which was limited at best. A basic descriptive analysis of the reported 'reasons for not using a mosquito net' data was not provided in eight out of the seventeen survey-based studies included in this review. This omission rendered it impossible to reliably interpret the relative importance of the reported findings in the respective studies. In the nine studies in which detailed descriptive analysis was presented, reliable interpretation of the data was often undermined by inadequate description of the study design. Examples included the frequent failure to report how data were obtained (e.g. in response to a structured checklist or open-ended question) or how many responses per participant were permissible. The omissions described above most probably reflect the fact that the focus of this review (reasons for not using a mosquito net as reported by mosquito net owners) was rarely a primary focus of the studies identified by the search methodology. Rather, the reviewed data were typically a relatively minor component of broader investigations of mosquito net use or malaria-related beliefs and practices. This in itself is a significant finding as it indicates an important area of investigation in the current environment of mass mosquito net distribution - why people who own/have available mosquito nets choose not to use them - has received minimal, dedicated, research attention.
In considering the recommendations made above it is also incumbent upon the reviewers to acknowledge that the survey-based data included in this review do not lend themselves readily to generalization and the pooled data must be interpreted with considerable caution. The respective surveys were variously conducted at different seasons or periods of high/low malaria transmission, a threat to cross-survey comparison and minimal data were obtained from non-African participants. In fact, the majority of reported data came from specific and diverse African sub-populations (e.g. pregnant women, caregivers of children under 5) and were often population specific (e.g. failure to use a mosquito net due to child-birth). Even seemingly generic reasons for not using a mosquito net, such as heat or perceived low mosquito density, may be more or less pertinent to specific populations, yet the quantity of currently available data is not sufficient to allow any such patterns to reliably emerge. Measures of mosquito net non-use were equally varied across the reviewed studies (rendering comparison difficult) and were often quite limited in scope; for example, not using a mosquito net the night prior to a survey. This measure, whilst convenient and clearly defined, does not allow a distinction to be made between individuals who never or rarely use a mosquito net, individuals who inconsistently use a mosquito net and individuals who usually use a mosquito net, but for whatever reason did not do so the night prior to survey. Reasons for not using a mosquito net, as well as interventions to encourage greater use, are likely to vary between these three categories of 'non-user'. Thus, the inability to identify the membership of these respective groupings, and their respective reasons for non-use, confounds informed and targeted intervention.
A further limitation of the reviewed reason for mosquito net non-use data was the paucity of qualitative investigation. The qualitative data included in the review were, as with the survey data, typically a minor component of the results presented in the respective studies. The one study in which the reported data were a primary research focus [16] employed a mixed methodology in which the qualitative component was highly structured, relatively minimal in scope and the level of analysis was limited and poorly described. This study was also distinct in that it examined the reasons why an identified mosquito net went unused as opposed to the reasons why an identified individual did not sleep under a mosquito net. Focusing on the net depersonalizes the line of questioning potentially resulting in honest more accurate data, gives a better sense of which mosquito net types (or states) may be more or less appealing and may allow use of an individual net to be tracked over time. However, by focusing on the net the reasons why the very individuals to whom the mosquito nets are provided do not always use them may go unreported or may be incorrectly reported (if someone other than the individual who would normally sleep under the net responds to the research questioning). The potential loss of, or inaccurate reporting of, relevant data inherent in study designs that focus on the net rather than the individual is of concern as it is these individuals that mosquito net promoting interventions or campaigns must target rather than the nets they choose not to use.
Taken together then, the omission of important information in many of the published survey findings, the constraints on generalization and the dearth of dedicated quantitative and especially qualitative investigation seriously undermine confidence in the reported findings of this review. The seemingly clear patterns evident in the reviewed data and the recommended interventions should, therefore, be considered highly tentative until such time as a greater quantity 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.
A balanced consideration of the results and recommendations presented above also requires overt acknowledgement of the limitations in the review itself. Grey (unpublished) literature was excluded from review as were the numerous and varied studies that have examined barriers to mosquito net use from perspectives other than that of identified owner/non-users. The latter studies, in particular, often provide instructive data on barriers to mosquito net use and warrant review in their own right. It was the opinion of the authors, however, that the limited scope of this review was justified on the grounds that the published data broadly pertaining to barriers to mosquito net use is so extensive and varied that it is better suited to multiple 'subject specific' reviews rather than a single general review. Other 'barrier to mosquito net' review topics may include: factors predictive of mosquito net use in households with and without sufficient mosquito nets; factors predictive of mosquito net ownership - and the number of mosquito nets owned - following a mass distribution campaign; and focussed investigations into locally specific barriers to mosquito net use.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
JP conceived of the study, conducted the review and drafted the manuscript, MWH, MB, PMS and IM conceived of the study and critically revised the manuscript. All authors' read and approved the final manuscript.
Acknowledgements
This review was financially supported by the Papua New Guinea National Malaria Control Program under the auspices of a Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) Round 8 grant.
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BEDNETS III: RAPID SCALE-UP OF ITN OWNERSHIP AND USE IN TANZANIA
Are nationwide catch-up LLIN campaigns the next big thing in malaria vector control? ‘ITN use among U5s [in mainland Tanzania] increased from 28.8% to 64.1%, a 2.2-fold increase.’
Good reading.
BD
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The electronic version of this article is the complete one and can be found online at: http://www.malariajournal.com/content/10/1/73
Design, implementation and evaluation of a national campaign to distribute nine million free LLINs to children under five years of age in Tanzania Kimberly Bonner1 , Alex Mwita1 , Peter D McElroy2 , Susan Omari1,3 , Ally Mzava1,3 , Christian Lengeler4,5 , Naomi Kaspar2 , Rose Nathan6 , Joyce Ngegba7 , Romanus Mtung'e8 and Nick Brown1,3 1 National Malaria Control Programme, Ministry of Health and Social Welfare, PO Box 9083, Dar es Salaam, Tanzania 2 President's Malaria Initiative, American Embassy PO Box 9123, Dar es Salaam, Tanzania 3 ITN Cell, Swiss Tropical and Public Health Institute, PO Box 3430, Dar es Salaam Tanzania 4 Health Interventions Unit, Swiss Tropical and Public Health Institute, PO Box 4002, Basel, Switzerland 5 University of Basel, Basel, Switzerland 6 Ifakara Health Institute, PO Box 78373, Dar es Salaam, Tanzania 7 World Vision Tanzania, PO Box 6399, Dar es Salaaim, Tanzania 8 Population Services International, PO Box 33500, Dar es Salaam, Tanzania author email corresponding author email Malaria Journal 2011, 10:73doi:10.1186/1475-2875-10-73 © 2011 Bonner et al; licensee BioMed Central Ltd. Abstract Background After a national voucher scheme in 2004 provided pregnant women and infants with highly subsidized insecticide-treated nets (ITNs), use among children under five years (U5s) in mainland Tanzania increased from 16% in 2004 to 26.2% in 2007. In 2008, the Ministry of Health and Social Welfare planned a catch-up campaign to rapidly and equitably deliver a free long-lasting insecticidal net (LLIN) to every child under five years in Tanzania. Methods The ITN Cell, a unit within the National Malaria Control Programme (NMCP), coordinated the campaign on behalf of the Ministry of Health and Social Welfare. Government contractors trained and facilitated local government officials to supervise village-level volunteers on a registration of all U5s and the distribution and issuing of LLINs. The registration results formed the basis for the LLIN order and delivery to village level. Caregivers brought their registration coupons to village issuing posts during a three-day period where they received LLINs for their U5s. Household surveys in five districts assessed ITN ownership and use immediately after the campaign. Results Nine donors contributed to the national campaign that purchased and distributed 9.0 million LLINs at an average cost of $7.07 per LLIN, including all campaign-associated activities. The campaign covered all eight zones of mainland Tanzania, the first region being covered separately during an integrated measles immunization/malaria LLIN distribution in August 2008, and was implemented one zone at a time from March 2009 until May 2010. ITN ownership at household level increased from Tanzania's 2008 national average of 45.7% to 63.4%, with significant regional variations. ITN use among U5s increased from 28.8% to 64.1%, a 2.2-fold increase, with increases ranging from 22.1-38.3% percentage points in different regions. Conclusion A national-level LLIN distribution strategy that fully engaged local government authorities helped avoid additional burden on the healthcare system. Distribution costs per net were comparable to other public health interventions. Particularly among rural residents, ITN ownership and use increased significantly for the intended beneficiaries. The upcoming universal LLIN distribution and further behaviour change communication will further improve ITN ownership and use in 2010-2011. Background Many African countries are in the midst of unprecedented efforts to rapidly scale-up coverage of malaria interventions, but considerable work remains. As recently as 2007-08, prevalence of Plasmodium falciparum parasitaemia exceeded 40% in some regions of Tanzania [1]. Through committed political leadership and support from multilateral and bilateral donors, mainland Tanzania now implements all four malaria control strategies recommended by the Roll Back Malaria (RBM) Partnership [2,3]. The strategies include insecticide-treated bed nets (ITNs) (since 2004), intermittent preventive treatment for pregnant women (since 2006), artemisinin-based combination therapy as first-line treatment (since 2007), and indoor residual spraying in selected areas (since 2008) [4]. However, scale-up of these interventions has not been uniformly achieved across all geographic areas of Tanzania, and disparity exists across urban/rural and wealth strata [5-9]. The National Insecticide-Treated Nets Programme (NATNETS) under the National Malaria Control Programme (NMCP) of the Ministry of Health and Social Welfare (MoHSW) is a multi-donor, multi-partner initiative to promote the national use of ITNs by making nets affordable, accessible, and acceptable. In 2004, NMCP initiated the Tanzania National Voucher Scheme (TNVS), a distribution mechanism supported by a Round 1 grant from the Global Fund to Fight AIDS, TB, and Malaria (GFATM) for delivering subsidized polyester nets bundled with insecticide treatment kits to pregnant women at antenatal visits [5]. Through support from the US President's Malaria Initiative in 2006, the TNVS added an infant voucher delivered at time of routine measles immunization. Between 2004 and 2007, the proportion of households owning at least one ITN rose from 23% to 39%. During this period, the proportion of children under five years of age (U5s), and the proportion of pregnant women sleeping under an ITN increased from 16% to 26% and 16% to 27%, respectively [2,10,11]. However, the MoHSW and NMCP considered these increases in ITN ownership and use too low to reach RBM targets of 80% by 2010. In 2007, following extensive stakeholder consultations, NMCP developed a plan in accordance with the current RBM strategy to rapidly increase ITN ownership and use through the procurement and delivery of a free long-lasting insecticidal nets (LLINs) to all U5s in mainland Tanzania [3,12]. This report summarizes the funding strategy for the national catch-up plan, as well as for the logistics and training to coordinate the timely and equitable delivery of LLINs at the village-level. It also presents the financial costs of this mass distribution and preliminary coverage data resulting therefrom. Methods Initiation and Financing of the U5 mass distribution campaign In March 2007, the GFATM invited Tanzania's Country Coordinating Mechanism (CCM) to submit a Rolling Continuation Channel (RCC) application to extend its Round 1 grant to increase ITN ownership and use among vulnerable groups. After extensive stakeholder discussions, NMCP proposed the continuation of the voucher programme plus the launch of a free, one-time LLIN distribution campaign for U5s (under five catch-up campaign - U5CC). The World Bank under its Booster Programme for Malaria Control in Africa and PMI simultaneously contributed funds to expand the scope of the distribution. In addition, Malaria No More/UNICEF, World Vision Switzerland, the UK Department for International Development (DfID), and the Swiss Agency for Development and Cooperation (SDC) contributed additional funding. Contributions raised during the Davos Economic Forum in 2005 and unobligated MoHSW funds closed the final budgetary gaps to complete the national campaign. Tendering and procurement of LLINs and sub-contractors In compliance with Tanzania's tendering rules and required product specifications, a single LLIN tender was issued by MoHSW funded by GFATM and the World Bank. LLINs financed by PMI were the subject of a separate tender. The only polyethylene net with the required qualifications at the time (2008), specifically a full WHO Pesticide Evaluation Scheme recommendation, was the Olyset® net produced by Sumitomo Chemical and A-Z Textiles Ltd. This requirement was exceptionally agreed to by the three donors in order to ensure that the same LLIN was delivered throughout the country following initial delays negotiating this issue with the different donors lasting several months. Because the local manufacturer (A-Z Textiles) also won the contract for distribution to village level, the management of the logistics was greatly facilitated. The five grant sub-recipients had already been identified through a competitive procurement mechanism conducted by the Country Coordinating Mechanism prior to the development of the RCC grant proposal. The MoHSW, through its Procurement Management Unit, contracted the grant sub-recipients for the five key components of the campaign: (1) Logistics - MEDA Economic Development Associates; (2) Training - World Vision Tanzania (WVT) (3) Social mobilization - Population Services International; (4) Monitoring and Evaluation - Ifakara Health Institute (IHI) who in turn sub-contracted technical support to the London School of Hygiene and Tropical Medicine; (5) Financial and procedural audit - KPMG. The proposal submission, evaluation and contracting process for the five sub-recipients took more than seven months to complete. The delivery contractor, (A to Z Textiles Ltd), was identified by the logistics contractor MEDA Economic Development Associates through a separate competitive tender. The LLIN Hang-up Campaign (conducted by Tanzania Red Cross) was separately contracted by USAID and co-funded by DfID. National coordination and regional stakeholder coordination Since 2003, the ITN Cell, a unit within the NMCP, has coordinated the National Insecticide-Treated Nets Program (NATNETS) programme, with technical and financial support from the Swiss Agency for Development and Cooperation through its executing agency, the Swiss Tropical and Public Health Institute. During the U5CC, the ITN Cell and other NMCP staff coordinated planning in Dar es Salaam and in the field where they facilitated contacts between the local government and the government contractors. The U5CC proceeded on a rolling basis, entering a new zone (comprising 2-3 regions each) every five weeks, while simultaneously completing later phases of the campaign in other zones. The U5CC covered Tanzania's eight zones in order of their malaria prevalence, with the zones having the highest malaria prevalence visited first. Tanzania's mainland population in 2009/10 exceeded 41 million, with over 80% living in areas with stable perennial to stable seasonal malaria transmission [4]. The U5CC started with a pilot programme in Mpanda District (highlighted in Figure 1) in October 2008 to test the planned methodology. The lessons from the pilot programme were incorporated into the main campaign, which is detailed below and diagrammed in Figure 2. Figure 1. United Republic of Tanzania, with Health Zones. Highlighted districts indicates locations of household surveys (1 Tanga, 2 South, 3 Lake, 4 West Lake, 5 South West, 6 Southern Highlands, 7 Central, 8 North, 9 Coast) Figure 2. Structure of the National, Regional, District and Local Government levels involved in the under-5 coverage campaign in Tanzania, 2008-09. Prior to departure of the field team (NMCP, ITN Cell and contractors' staff) from Dar es Salaam, the MoHSW sent a letter to Regional and District government officials, alerting them to the upcoming U5CC in their respective regions and districts. Upon arrival in a region, the field team-consisting of contractors and an ITN Cell representative-jointly briefed the regional government authorities on the U5CC. The training contractor organized regional sensitization meetings for the regional authorities including the regional health management teams who had a role in regional supervision. District-level activities Courtesy calls At the district level, the field team engaged the District Medical Officer and the District Executive Director, briefed them on their U5CC related responsibilities and the need to invite local government officials, Ward and Village Executive Officers - WEOs and VEOs, to a training session on their oversight role in the U5CC. Any unfinished micro-planning was completed with the assistance of the district Malaria Focal Person. These Malaria Focal Persons are part of the district Council Health Management Teams (CHMT) and are responsible for coordinating all malaria-related activities in their district. The post was established in each of mainland Tanzania's 121 Districts in 2004 [13,14]. Sensitization and training Following the introductory courtesy calls, the training contractor conducted sensitization meetings with the relevant district authorities, including the Council Health Management Teams, who played a critical role in supervision, report collection, and payments to volunteers engaged in the household registration and LLIN issuing processes. Immediately after the sensitization meeting, the training contractor conducted a two-day training session for WEOs and VEOs at each of the district's four to six divisions. WEOs and VEOs were trained on their responsibilities as direct supervisors of the village volunteers who conducted household registration and LLIN issuing processes. WEOs and VEOs received illustrated guides as a reference during supervision. VEOs were responsible for village volunteers' selection and training, oversight of LLIN storage and final distribution of the LLINs from the storage space to the village government posts where nets were issued during three campaign days (Friday-Sunday). Household registration Upon returning to their villages, VEOs selected four healthy, literate and respected members of the community to conduct a house-to-house registration. This five-day process involved recording the names of every U5 at each household in the village in the U5CC register book. The volunteers provided the child's care-givers with a sequentially numbered coupon (identifying the recipient's place in the register book) and instructions to bring the coupon to the LLIN issuing point on one of the designated issuing days. Upon the completion of registration, volunteers submitted their register books to the VEO who compiled all data into a village registration report. These village reports provided an estimate for the number of children eligible for an LLIN, including an estimate of the number of children missed during the registration, based upon the VEOs' data on U5s in the village. The WEO combined all village registration reports into a ward registration report, which the Council Health Management Teams collected while making payments for the registration process. Community sensitization Before and during each registration, the social mobilization contractor conducted promotional activities in the area to encourage residents to participate in registration. These activities included road shows, mobile video units (entertaining health-related documentaries displayed on large screens) public meetings, public address broadcasts from vehicles, radio discussions, radio advertisements, and print media. LLIN delivery, distribution, and issuing Delivery and distribution The LLIN needs for each zone were compiled into a village-level packing list and reviewed and approved by NMCP prior to order placement. In addition, the distribution contractor (also A-Z Textiles Ltd) was responsible for delivering (via truck) the appropriate number of LLINs to every village in a zone within 30 days of receipt of the order. These deliveries included enough LLINs to meet the village registration requirements as well as a 5% village buffer for unregistered children, an additional 5% bale rounding factor and (initially) a further 5% buffer at district level to compensate for any additional shortfalls in the villages. Upon reaching the village, A-Z Textiles delivered the LLINs only after the VEO provided a signature and official stamp to receive them, as the VEO was the custodian of the LLINs until the were issued. In preparation for issuing, each VEO then selected and trained two new volunteers on the LLIN issuing process and supervised the transfer of LLINs from their secure storage locations to the one or two issuing posts in each village. Social mobilization In the weeks preceding LLIN issuing, the social mobilization contractor returned to the regions with radio broadcasts, print materials, road shows, and mobile video units to prepare the public for the delivery of the nets. LLIN issuing Issuing was conducted over a weekend in order to ensure the maximum number of people was at home, yet always started on a Friday to reduce congestion from too many people attending on the first day. Caregivers of U5s were instructed to visit the issuing posts with their numbered coupons during any of the three LLIN issuing days. They were not required to bring their children provided they had been pre-registered. The caregivers presented their coupons to the volunteers, who verified the entry in the register book. Caregivers confirmed receipt of the nets, and the fingers of children (if present) were marked with indelible ink. Unregistered children On the final day of net issuing, volunteers began recording the names of children missed during the initial registration. These children received LLINs from the village or ward-level buffer stocks. Upon completion of issuing days, the VEO compiled a village-level report on the LLIN issuing and submitted it to the WEO, who prepared a ward-level report. These reports were collected by the Council Health Management Team members when they returned to the wards to make LLIN issuing payments. Unissued nets were distributed to any remaining unregistered U5s and then to vulnerable members of the community, including people living with HIV/AIDS, elderly, disabled, or very ill people, as identified by the village council. LLIN hang-up campaign Approximately one month after LLIN issuance, an organized effort was made to encourage household members to hang-up and use their new LLINs. The effort was implemented by the Tanzania Red Cross volunteer network and local government officials (including WEOs and VEOs) in each zone. In areas lacking a Red Cross volunteer structure, division-level extension officers worked as supervisors and ward health workers served as volunteers. With one volunteer per village, each volunteer had 12 days to visit every household in the village to ensure the new LLIN was hung and used and to share malaria messages with residents by distributing illustrated leaflets. Volunteer reports were collected by local supervisors and entered into a national database. Monitoring and evaluation The monitoring and evaluation contractor, Ifakara Health Institute, assisted by the London School of Hygiene and Tropical Medicine, conducted a series of post-distribution district household surveys on ITN coverage and other U5CC related activities one to three months following net issuing in a given zone. Districts were selected based upon the availability of baseline data from a 2008 nationally representative malaria survey, including five Districts, (Figure 1 - Ifakara Health Institute and the London School of Hygiene and Tropical Medicine 2009, unpublished data). From each district, 30 clusters (villages) were selected with probability proportional to the size of the village. Within each selected cluster, one sub-village was chosen randomly and 30 households were chosen from that sub-village, based upon a modified Expanded Immunization Programme sampling procedure [15]. Questions about household ownership and use were asked using the standardized Malaria Indicator Survey format Results Total campaign financial cost Nine different donors funded the U5CC (Table 1), and contributions ranged from $25,258,382 (GFATM) to $317,817 (Davos World Economic Forum Fund). Table 1 represents the direct financial costs for the U5CC, not including local government contributions. All of these funds were provided in unadjusted USD, with the exception of the Swiss Agency for Development and Cooperation and MoHSW contributions, which were calculated in USD based upon the exchange rate at the time of money transfer. The primary donors (GFATM, World Bank, and PMI) committed funds in 2008. The overall cost of the U5CC totaled USD $63,831,113, of which USD $47,340,943 (74.2%) was used to purchase 9,034,677 LLINs. The financial cost per LLINs distributed was USD $7.07 per LLIN, of which USD $5.24 were used to purchased the net, and USD $1.83 were for LLIN transport, training, logistics, management, social mobilization/BCC, and M&E. Table 1. Financial Costs (in un-adjusted United States Dollars) of an LLIN distribution by cost category and donor LLIN procurement and delivery Towards the end of the campaign, the U5CC faced a 1,822,954 LLIN shortfall due to the difference between the estimated number of LLINs needed for the U5s (original budget) and the actual numbers of LLINs ordered based upon the household registration process. The original budget relied upon National Bureau of Statistics (NBS) 2008 population projections from the 2002 Tanzania National Census, which projected a need for 7,220,083 LLINs. However, the actual order for LLINs in the first two zones (Southern and Lake) surpassed the original projections by 42%. An analysis detailed in Table 2 showed six main contributions to the discrepancy between the NBS estimates and actual LLIN needs. A total of 20.2% could be attributed to various buffers: 5% as village buffer, 5% at district level, 5% due to bale-rounding because only full bales of 40 LLINs were delivered to the village level, and a village level estimate of unregistered children capped at 5% of the total village LLIN order. A comparison between the NBS projections and 4,000 entries in a sample of U5CC register books from 12 villages indicated that another 7% of the discrepancy could be attributed to registration of overage children (>59 months), particularly five-year old children. The source of the remaining 14.8% discrepancy was most likely due to an NBS projection error or inaccurate census data in 2002. Table 3 illustrates the discrepancy between NBS estimates and LLIN orders on a zone basis. The total number of buffer LLINs provided for each zone was simply the difference between U5s registered and total LLINs sent. Table 2. Components of the discrepancy between 2008 National Bureau of Statistics (NBS) estimates for children under five years and the actual LLIN order in Southern and Lake Zones Table 3. Estimated and actual number of children under five years of age for determining LLIN needs by Zone, Tanzania, 2008-09 LLIN distribution and issuing Following the Table 2 analysis (conducted after LLIN issuing in the first two zones), policies on buffer stocks became more restrictive to reduce the anticipated future shortfall of nets. Overall, the vast majority (96.1%) of children that attended issuing posts received LLINs, as illustrated in Table 3. This included the children registered by volunteers as well as the children missed in the registration process who received LLINs from buffer stocks. Village reports documented that a total of 222,712 LLINs (the difference between LLINs delivered to a village and LLINs issued to U5s) were delivered to villages in excess of the village's U5 registered population. These LLINs were reallocated to 1) unregistered U5s in the village; 2) unregistered U5s in the ward; and (if any surplus LLINs remained) to needy members of the community. While the village and ward authorities were tasked with reallocating the LLIN surpluses, this occurred after the reporting period ended, so there is no data on this re-allocation. Table 4 details the line item costs associated with the U5CC implementation in one of mainland Tanzania's 121 districts. The U5CC budget for Rural Kyela District was selected as an illustrative example of components of U5CC district budgets. This district is smaller in U5 population (38,007) than the average Tanzanian district (68,444), but the contractor budgets were comparable to other Tanzanian districts [16]. These costs exclude the LLIN procurement and delivery to village. Table 4. Actual U5CC costs by activity, Kyela District, Tanzania Hang-up campaign Net coverage following campaign The map in Figure 1 indicates the districts selected for post-U5CC surveys (Nachingwea, Mtwara Urban, Sengerema, Chato, and Rorya) as well as the Mpanda pilot district. Household ITN ownership increased from a national average of 45.7% in 2008 to 63.4% in 2009 (ranging from 60.8% in the South Zone to 82.0% in the Lake Zone). Children under five years (U5s) ITN coverage following the Roll Back Malaria definition means the percentage of U5s sleeping under an ITN the night before the survey. It increased nationally from 28.8% in 2008 to 64.1% in 2009, a 2.2-fold increase. Increases ranged from 25.9% to 48.0% in the Southern Zone and 23.9% to 62.2% in the Lake Zone. The Tanzania Red Cross reported that volunteers visited households with a total of 9,080,232 U5s and assisted in hanging 1,702,840 LLINs. The 2009-2010 Demographic Health Survey took place following the U5CC and Hang-up Campaign in 14 regions, at the same time of the campaign in five regions, and before the campaigns in the remaining three regions. These additional ITN coverage data are presented in the Discussion. Discussion The combination of funding sources was in itself an achievement, demonstrating the attractiveness of the U5CC to donors and hence the willingness of numerous agencies to collaborate [17]. However, achieving agreement among the main donors on LLIN tender specifications represented a particular challenge. Initially the MoHSW expressed its preference for a more durable (but also more expensive) polyethylene net, but GFATM, PMI and World Bank's procurement regulations precluded this without a clear and objective justification. After negotiations, MoHSW and these three donors reached a consensus that met the requirements for Tanzania's LLIN policy. At USD $7.07 (unadjusted) per LLIN, Tanzania's distribution compares favorably with other recent LLIN deliveries, including distributions in Eritrea, Malawi, Senegal, and Togo, as well as Tanzania's ongoing LLIN voucher plan for pregnant women and infants. The free or partially subsidized distribution costs in these countries ranged from USD $6.90 to $9.50 and their mechanisms included both public and mixed public private sector distributions [18,19]. The U5CC used local government employees rather than health workers to avoid further burdening the Tanzanian healthcare system. This was a major strength of the campaign because 66% of Tanzania's healthcare staff positions are unfilled [20]. As civil servants, these local government officials were not affiliated with any political party and most had offices where the LLINs could be securely stored until the issuing was completed. In addition, these officials reported directly to their District Executive Directors, who had already expressed support for the successful completion of the U5CC. Further, the U5CC engaged community leadership to help increase accountability and transparency. The U5CC roll-out in a given zone occurred in a 3-month cycle, with one month for training and sensitization, one month for registration, report writing and LLIN order placement, and one month for LLIN delivery, issuing, and report writing. The registration process provided village-level details of LLIN needs and intended recipients, an unprecedented level of detail and transparency. In addition, A-Z Textiles required 30 days to deliver the exact number of LLINs requested to each village in the zone. This contrasts with the delivery mechanisms in Zambia in 2003, which did not have a registration and where local authorities were responsible for moving the ITNs to village level [21]. The longer time-frames of the U5CC roll-out were a result of both the accuracy of the LLIN distribution and the scale of the LLIN distribution in each zone, where over a million LLINs were delivered. Every five weeks, the training and sensitization team entered a new zone to begin training, as registration continued in the previous zone and LLIN issuing continued in the zone before that. Because each zone contained two to three regions, the respective capacities of the contractors could not accommodate additional regions or zones in the month-by-month roll-out. While this necessitated a total of twelve months before U5CC completion, it also enabled the coordinators to closely monitor the roll-out in each region and to address problems or shortfalls. For distributions covering a several district or small countries such as Togo, all of the U5 LLINs were distributed over a short period as part of an integrated campaign [22,23]. Because of Tanzania's size, each of the eight zone LLIN distributions was approximately the size of Togo's entire national LLIN distribution campaign [23]. Following the receipt of the registration data and LLIN order placement in the first two zones, it was apparent that LLINs distributed according to the registration figures plus the village (5%), bale rounding (5%) and district level (5%) buffers would lead to a significant funding shortfall and there would be insufficient nets for the whole country. These buffers had been introduced following the widespread LLIN shortfalls in the Mpanda District pilot distribution when the LLIN order exactly matched the house-to-house registration data. As a result, NMCP assessed the discrepancies between the original NBS data and the actual LLIN needs for each region in the first two zones. It was decided that the district buffer and the additional bale-rounding buffer could be eliminated to conserve LLINs for the later stages of the campaign. Despite the elimination of two buffers, the U5CC still faced an additional USD $10 million shortfall to distribute LLINs in all zones. The U5CC coordinators solicited funds from donors to close this gap. The final contribution of $1,993,046 from the Tanzanian government supported the purchase of LLINs for the three districts of Dar es Salaam, which allowed the U5CC to draw to a close. As a result of the buffer reductions, 451,965 U5s who had not registered for the U5CC, but had gone to issuing points to receive an LLIN left without one. These children will receive free LLINs in the upcoming universal coverage campaign, supported by GFATM Round 8. Preliminary data in the first two zones showed marked improvement in two of the RBM core indicators: ITN ownership and U5 ITN use. In both zones, U5 ITN use lagged behind ownership by 12-20 percentage points. This is consistent with other mass LLIN distribution campaigns where percentage point gaps of 36.0 and 36.1 between ownership and use were noted in Kenyan household members and Ghanaian U5s, respectively [24,25]. An assessment of LLIN needs for sub-Saharan Africa have assumed 55% ITN use with 80% ITN ownership [26]. Additional behavioural change communication to address the importance of sleeping under an ITN every night will likely assist in closing this gap [27]. The NMCP launched a "focal parents programme" and a "community change agent programme" to assist in improving ITN use at the community level through the training of key community members on malaria prevention and treatment. Even before these behavioural change efforts reach full scale-up, Tanzania has experienced improvements as described in the preliminary report of the 2009-10 DHS [11]. ITN use among children under five years and pregnant women are currently at similar levels as household ownership of at least one ITN (Table 5.) Figure 3 indicates that equity in U5 ITN coverage improved significantly following the U5CC. Table 5. Household ITN ownership & ITN use among children under five years of age determined through household surveys, Tanzania, 2008 (pre-campaign) - 2009 (post-campaign) Figure 3. A comparison of U5 ITN coverage between urban and rural populations from three nationally representative surveys. The U5CC will be immediately followed by a universal coverage campaign funded by GFATM Round 8. The goal of this additional campaign is to provide 18 million LLINs for every sleeping space not covered by an U5CC LLIN. Beyond these free distribution (catch-up) campaigns, future free LLIN distributions remain uncertain. However, a regular mechanism of sustaining the current high ITN coverage through continuous distribution mechanisms is clearly needed. Tanzania has developed and sustained an ITN voucher programme for pregnant women and infants since 2004 [6,7,16]. This successful voucher programme was recently upgraded by the Global Fund RCC and PMI to provide an LLIN with a fixed co-payment of TSH 500 (approximately US $0.35) per voucher redemption. If funding continues, this mechanism will serve as one part of the national keep-up strategy until a new policy for ITN distribution is developed. Additional mechanisms for ITN distribution will be needed to ensure a sufficient, continuous flow of replacement ITNs to the Tanzanian population to sustain high ITN coverage rates. This is a situation common to all countries that have completed campaigns, and more discussions at both national and global level are urgently required to explore the best possible options for the future. List of abbreviations CHMT: Council Health Management Team; DED: District Executive Director; DfID: Department for International Development; DHS: Demographic Health Survey; GFATM: Global Fund to Fight AIDS TB and Malaria; IHI: Ifakara Health Institute; ITN: Insecticide-treated net; LLIN: Long-lasting insecticidal net; LSHTM: London School of Tropical Medicine and Hygiene; MEDA: MEDA Economic Development Associates; MFP: Malaria Focal Person; MoHSW: Ministry of Health and Social Welfare; NATNETS: National Insecticide-Treated Nets Program; NBS: National Bureau of Statistics; NMCP: National Malaria Control Program; PMI: Presidents Malaria Initiative; RBM: Roll Back Malaria; RCC: Rolling Continuation Channel; RHMT: Regional Health Management Team; SDC: Swiss Agency for Development and Cooperation; Swiss TPH: Swiss Tropical and Public Health Institute; TNVS: Tanzania National Voucher Scheme; TRC: Tanzania Red Cross; U5: Child under five years of age; U5CC: Under 5 Catch-up Campaign; USD: Unites States Dollars; VEO: Village Executive Officer; WEF: World Economic Forum; WEO: Ward Executive Officer; WVT: World Vision Tanzania; Competing interests The authors declare that they have no competing interests. Authors' contributions AM, CL & NJ designed the methodology and JN, RM, SO & AM made substantial contributions to the implementation and the analysis of the methodology. RN provided data on the results of the methodology and provided substantial contributions to the manuscript. NK participated in methodology implementation and coordination of the manuscript development and approval. PM made substantial contributions to the design of the methodology and extensive contributions to the development, drafting, analysis, and editing of the manuscript. KB participated in the implementation of the methodology and drafted the manuscript. All authors read and approved the final manuscript. Acknowledgements The researchers would like to thank the Under 5 Catch-up Campaign implementation team as well as the Ministry of Health and Social Welfare and the Ministry of Local Government for their hard work in implementing the campaign. The opinions and assertions expressed herein are those of the authors and do not necessarily reflect the official position or policies of their respective organizations. References
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