Challenges and opportunities associated with the introduction of next generation long lasting insecticidal nets for malaria control: a case study from Burkina Faso.

BACKGROUND Reductions in malaria incidence in Africa can largely be attributed to increases in malaria vector control activities; predominately the use of long lasting insecticidal nets (LLINs). With insecticide resistance affecting an increasing number of malaria endemic countries and threatening the effectiveness of conventional LLINs, there is an increasing urgency to implement alternative tools that control these resistant populations. The aim of this study was to identify potential challenges and opportunities for accelerating access to next generation LLINs in Burkina Faso, a country with areas of high levels of insecticide resistance. METHODS An analytical framework was used to guide the selection of interviewees, data collection and analysis. Semi structured interviews were carried out with key informants in April 2014 in Burkina Faso. Interviews were conducted in French and English, audio recorded, transcribed and entered into NVivo10 for data management and analysis. Data were coded according to the framework themes and then analysed to provide a description of the key points and explain patterns in the data. RESULTS Interviewees reported that the policy architecture in Burkina Faso is characterised by a strong framework of actors that contribute to policymaking and strong national research capacity which indirectly contributes to national policy change via collaboration with internationally led research. Financing significantly impacts the potential adoption, availability and affordability of next generation LLINs. This confers significant power on international donors that fund vector control. National decisions around which LLINs to procure were restricted to quantity and delivery dates; the potential to tackle insecticide resistance was not part of the decision-making process. Furthermore, at the time of the study there was no World Health Organisation (WHO) guidance on where and when next generation LLINs might positively impact on malaria transmission, severely limiting their adoption, availability and affordability. CONCLUSIONS This study shows that access to next generation LLINs was severely compromised by the lack of global guidance. In a country like Burkina Faso where WHO recommendations are relatively quickly adopted, a clear WHO recommendation and adequate financing will be key to accelerate access to next generation LLINs. Key Words: Malaria, Next generation long lasting insecticidal nets, LLINs, PBO nets, Policy Analysis, Vector Control, Burkina Faso

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Behavioural determinants of malaria risk, prevention, and care-seeking behaviours among forest-goers in Cambodia

Abstract Background Cambodia has made significant progress towards achieving malaria elimination by 2025. Cases continue to decrease and are primarily concentrated in forested areas. Forest-goers are most at risk of malaria due to their proximity to the forest, poor sleeping conditions, frequent mobility, and distance from health services. Consistent use of long-lasting insecticidal nets or hammock nets (LLINs/LLIHNs), early diagnosis and treatment of cases are central to reducing disease burden. The aim of this study was to understand forest-goers’ knowledge, attitudes, and practices related to malaria prevention and care-seeking, and to identify key behavioural determinants of LLIN/LLIHN use and prompt care-seeking within 24 h of developing a fever. Methods A mixed-methods study design consisting of a cross-sectional survey and qualitative in-depth interviews was implemented in two Cambodian provinces. Survey participants (N = 654) were recruited using respondent driven sampling. Interview participants (N = 28) were selected using purposive sampling. Findings from the survey were analysed using univariate and bivariate analysis and multivariate weighted logistic regression. Interviews were coded and analysed using thematic content analysis. Results All study participants had heard of malaria and 98% knew that malaria was transmitted by mosquitoes. LLIN/LLIHN ownership was high (94%). Although 99% of participants perceived LLIN/LLIHN use as an important malaria prevention measure, only 76% reported using one during their last visit to the forest. Only 39% of survey participants who reported seeking care did so within the recommended 24 h from fever onset during their last febrile illness. Among all study participants, 43% did not seek any healthcare during their last febrile episode. In controlled regression models, perceived community social norms were significantly associated with LLIN/LLIHN use (OR: 2.7, 96% CI 1.99–2.64) and care-seeking within 24 h of fever onset (OR: 1.7, 95% CI 1.00–2.88). Social support from other forest-goers was also significantly associated with LLIN/LLIHN use (OR: 4.9, 95% CI 1.32–18.12). Conclusions Study findings are consistent with other studies on LLIN/LLIHN use and care-seeking behaviours. While rates of LLIN/LLIHN ownership were high among the study population, rates of use were not as high. More concerning were the delayed care-seeking behaviours. Social behaviour change activities should incorporate social norms and social support as mechanisms for behaviour change given the identified positive correlations with LLIN/LLIHN use and prompt care-seeking