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.

Assessing Knowledge and Factors Associated to Long Lasting Insecticide Nets use among pregnant women in southern Rwanda

Background Around 443,000 pregnant women are at risk of malaria each year in Rwanda. LLINs are freely distributed to women at health centers during antenatal care visit and vaccination services. Methods A cross-sectional design was used to explore pregnant women’s knowledge and factors associated to LLINs use in five cells of Tumba sector. Data was collected through interviews and questionnaires. The data was analyzed using SPSS 21. Bivariate and multivariate analyses were performed with Chi-square test to assess the association between LLINs ownership and utilization of LLINs. Results All respondents had high knowledge and knew that sleeping under LLINs helps to avoid mosquito bites whereas 381 (99.2%) knew that the use of LLIN helps to fight against the burden of malaria. LLIN ownership was 323 (84.1%) while usage was 283 (87.6%) among LLINs owners. LLIN ownership is significantly influenced by the level of education (p=0.001) and utilization (p=0.001). Although LLINs coverage was high, its utilization was low. Sixty-one respondents (15.9 %) do not have LLINs and 84 (22%) of respondents had low knowledge on LLINs. Conclusion Regular training on LLINs may increase awareness of pregnant women on the benefits of LLIN utilization. Keywords: Malaria; Households; Long-lasting insecticidal nets; Ownership; Rwanda

Ownership, Coverage, Utilisation and Maintenance of Long-lasting insecticidal nets (LLINs) in Bamenda, Santa and Tiko Health Districts in Cameroon

IntroductionThe Bamenda, Santa and Tiko Health Districts are in the highest malaria transmission strata of Cameroon. The purpose of this study was to explore the indicators of ownership and utilisation as well as maintenance of long-lasting insecticidal nets (LLINs) in three health districts in Cameroon.MethodsA cross-sectional household survey involving 1,251 households was conducted in the Tiko Health District (THD) in July and June 2017 and in Bamenda and Santa Health Districts in March to May 2018. A structured questionnaire was used to collect data on LLIN ownership, utilisation and maintenance as well as demographic characteristics.ResultsThe average number of LLINs per household was higher in the Bamenda Health District (BHD) compared to the Tiko Health District (THD) (2.5±1.2 vs. 2.4±1.6) as well as the household ownership at least one LLIN (93.30% vs. 89.00%). The proportion of the de-facto population with universal utilisation was higher in BHD compared to THD (13.1% vs 0.2%). In multinomial regression analysis, households in the SHD (p = 0.007, OR; 2.8, 95% C.I; 1.3 – 5.8), were more likely to own at least one LLIN compared to those in THD.ConclusionOwnership of LLINs was low in SHD and THD in comparison to the goal of one for every two household members. Overall LLINs coverage and accessibility was still low after the free MDCs, as only 14.6% of children 0 – 5 years and 16.1% of the entire population used LLIN the night before the survey.

Factors Associated with Coverage and Usage of Long-Lasting Insecticidal Nets in Madagascar

In October 2007, long-lasting insecticidal nets (LLINs) were distributed in 59 of the 111 districts in Madagascar as part of a nationwide child survival campaign. A community-based cross-sectional survey was conducted six months post-campaign to evaluate net ownership, use and equity. Here, we examined the effects of socioeconomic factors on LLIN ownership and usage in districts with and without net distribution during the campaign. Our data demonstrated that in districts with LLIN distribution, LLIN ownership was similar across all wealth groups in households with at least one child under the age of five years (90.5% versus 88.6%); in districts without net distribution, 57.8% of households in the poorest tertile compared to 90.1% of households in the least poor tertile owned at least one LLIN. In contrast, in LLIN-owning households, both in districts with and without net distribution, higher socio-economic status was not associated with use among children under five years. These findings suggest that socio-economic status contributes to the household net ownership but once a household owns a net, socio-economic status is not associated with net use.