The impact of a hybrid social marketing intervention on inequities in access, ownership and use of insecticide-treated nets

BACKGROUND: An ITN intervention was initiated in three predominantly rural districts of Eastern Province, Zambia, that lacked commercial distribution and communication infrastructures. Social marketing techniques were used for product and message development. Public sector clinics and village-based volunteers promoted and distributed subsidized ITNs priced at $2.5 per net. A study was conducted to assess the effects of the intervention on inequities in knowledge, access, ownership and use of ITNs. METHODS: A post-test only quasi-experimental study design was used to compare intervention and comparison districts. A total of 2,986 respondents were interviewed. Survey respondents were grouped into four socio-economic (SES) categories: low, medium-low, medium and high. Knowledge, access, ownership and use indicators are compared. Concentration index scores are calculated. Interactions between intervention status and SES help determine how different SES groups benefited from the intervention. RESULTS: Although overall use of nets remained relatively low, post-test data show that knowledge, access, ownership and use of mosquito nets was higher in intervention districts. A decline in SES inequity in access to nets occurred in intervention districts, resulting from a disproportionately greater increase in access among the low SES group. Declines in SES inequities in net ownership and use of nets were associated with the intervention. The largest increases in net ownership and use occurred among medium and high SES categories. CONCLUSION: Increasing access to nets among the poorest respondents in rural areas may not lead to increases in net use unless the price of nets is no longer a barrier to their purchase

Geographical disparities in core population coverage indicators for roll back malaria in Malawi

BACKGROUND: Implementation of known effective interventions would necessitate the reduction of malaria burden by half by the year 2010. Identifying geographical disparities of coverage of these interventions at small area level is useful to inform where greatest scaling-up efforts should be concentrated. They also provide baseline data against which future scaling-up of interventions can be compared. However, population data are not always available at local level. This study applied spatial smoothing methods to generate maps at subdistrict level in Malawi to serve such purposes. METHODS: Data for the following responses from the 2000 Malawi Demographic and Health Survey (DHS) were aggregated at subdistrict level: (1) households possessing at least one bednet; (2) children under 5 years who slept under a bednet the night before the survey; (3) bednets retreated with insecticide within past 6-12 months preceding the survey; (4) children under 5 who had fever two weeks before the survey and received treatment within 24 hours from the onset of fever; and (5) women who received intermittent preventive treatment of malaria during their last pregnancy. Each response was geographically smoothed at subdistrict level by applying conditional autoregressive models using Markov Chain Monte Carlo simulation techniques. RESULTS: The underlying geographical patterns of coverage of indicators were more clear in the smoothed maps than in the original unsmoothed maps, with relatively high coverage in urban areas than in rural areas for all indicators. The percentage of households possessing at least one bednet was 19% (95% credible interval (CI): 16-21%), with 9% (95% CI: 7-11%) of children sleeping under a net, while 18% (95% CI: 16-19%) of households had retreated their nets within past 12 months prior to the survey. The northern region and lakeshore areas had high bednet coverage, but low usage and re-treatment rates. Coverage rate of children who received antimalarial treatment within 24 hours after onset of fever was consistently low for most parts of the country, with mean coverage of 4.8% (95% CI: 4.5-5.0%). About 48% (95% CI: 47-50%) of women received antimalarial prophylaxis during their pregnancy, with highest rates in the southern and northern areas. CONCLUSION: The striking geographical patterns, for example between predominantly urban and rural areas, may reflect spatial differences in provider compliance or coverage, and can partly be explained by socio-economic and cultural differences. The wide gap between high bed net coverage and low retreatment rates may reflect variation in perceptions about malaria, which may be addressed by implementing information, education and communication campaigns or introducing long lasting insecticide nets. Our results demonstrate that DHS data, with appropriate methodology, can provide acceptable estimates at sub-national level for monitoring and evaluation of malaria control goals

Explaining inconsistencies between data on condom use and condom sales

BACKGROUND: Several HIV prevention programs use data on condom sales and survey-based data on condom prevalence to monitor progress. However, such indicators are not always consistent. This paper aims to explain these inconsistencies and to assess whether the number of sex acts and the number of condoms used can be estimated from survey data. This would be useful for program managers, as it would enable estimation of the number of condoms needed for different target groups. METHODS: We use data from six Demographic and Health Surveys to estimate the total annual number of sex acts and number of condoms used. Estimates of the number of sex acts are based on self-reported coital frequency, the proportion reporting intercourse the previous day, and survival methods. Estimates of the number of condoms used are based on self-reported frequency of use, the proportion reporting condom use the previous day and in last intercourse. The estimated number of condoms used is then compared with reported data on condom sales and distribution. RESULTS: Analysis of data on the annual number of condoms sold and distributed to the trade reveals very erratic patterns, which reflect stock-ups at various levels in the distribution chain. Consequently, condom sales data are a very poor indicator of the level of condom use. Estimates of both the number of sexual acts and the number of condoms used vary enormously based on the estimation method used. For several surveys, the highest estimate of the annual number of condoms used is tenfold that of the lowest estimate. CONCLUSIONS: Condom sales to the trade are a poor indicator of levels of condom use, and are therefore insufficient to monitor HIV prevention programs. While survey data on condom prevalence allow more detailed monitoring, converting such data to an estimated number of sex acts and condoms used is not straightforward. The estimation methods yield widely different results, and it is impossible to determine which method is most accurate. Until the reliability of these various estimation methods can be established, estimating the annual number of condoms used from survey data will not be feasible. Collecting survey data on the number of sex acts and the number of condoms used in a fixed time period may enable the calculation of more reliable estimates of the number of sex acts and condoms used

Adolescent fertility and family planning in East Asia and the Pacific: a review of DHS reports

<p>Abstract</p> <p>Background</p> <p>Adolescent pregnancy has significant health and socio-economic consequences for women, their families and communities. Efforts to prevent too-early pregnancy rely on accurate information about adolescents' knowledge, behaviours and access to family planning, however available data are limited in some settings. Demographic and Health Survey (DHS) reports are recognised as providing nationally representative data that are accessible to policymakers and programmers. This paper reviews DHS reports for low and lower middle income countries in East Asia and the Pacific to determine what information regarding adolescent fertility and family planning is available, and summarises key findings.</p> <p>Methods</p> <p>The most recent DHS reports were sought for the 33 low and lower middle income countries in the East Asia and Pacific region as defined by UNICEF and World Bank. Age-disaggregated data for all indicators relevant to fertility and current use, knowledge and access to family planning information and services were sought to identify accessible information. Reported data were analysed using an Excel database to determine outcomes for adolescents and compare with adult women.</p> <p>Results</p> <p>DHS reports were available for eleven countries: Cambodia, Indonesia, Marshall Islands, Nauru, Papua New Guinea, Philippines, Samoa, Solomon Islands, Timor-Leste, Tuvalu and Vietnam. Twenty seven of 40 relevant DHS indicators reported outcomes for adolescent women aged 15-19 years. There were limited data for unmarried adolescents. A significant proportion of women commence sexual activity and childbearing during adolescence in the context of low contraceptive prevalence and high unmet need for contraception. Adolescent women have lower use of contraception, poorer knowledge of family planning and less access to information and services than adult women.</p> <p>Conclusion</p> <p>DHS reports provide useful and accessible data, however, they are limited by the failure to report data for unmarried adolescents and report age-disaggregated data for some indicators. Further research is required to better understand the barriers that both married and unmarried adolescents face accessing reproductive health information and services, and their information and service delivery preferences.</p

A qualitative study to identify community structures for management of severe malaria: a basis for introducing rectal artesunate in the under five years children in Nakonde District of Zambia

BACKGROUND: Malaria is a serious illness among children aged 5 years and below in Zambia, which carries with it many adverse effects including anemia and high parasites exposure that lead to infant and childhood mortality. Due to poor accessibility to modern health facilities, malaria is normally managed at home using indigenous and cosmopolitan medicines. In view of problems and implications associated with management of severe malaria at home, rectal artesunate is being proposed as a first aid drug to slow down multiplication of parasites in children before accessing appropriate treatment. METHODS: A qualitative study using standardised in-depth and Focuss Group Discussions (FGDs) guides to collect information from four (4) villages in Nakonde district, was conducted between February and March 2004. The guides were administered on 29 key informants living in the community and those whose children were admitted in the health facility. Participants in the 12 FGDs came from the 4 participating villages. Participants and key informants were fathers, younger and older mothers including grandmothers and other influential people at household level. Others were traditional healers, headmen, village secretaries, tradtional birth attendants, church leaders and black smiths. FGDs and interview transcriptions were coded to identify common themes that were related to recognition, classification and naming of malaria illness, care-seeking behaviour and community treatment practices for severe malaria. RESULTS: Parental prior knowledge of the disease was important as the majority of informants (23 out of 29) and participants (69 out of 97) mentioned four combined symptoms that were used to recognise severe malaria. The symptoms were excessive body hotness, convulsions, vomiting yellow things and bulging of the fontanelle. On the other hand, all informants mentioned two or more of symptoms associated with severe malaria. In all 12 FGDs, participants reported that treatment of severe malaria commenced with the family and moved into the community as the illness progressed. Although treatment of severe diarrheal effects, were common among the winamwanga, no rectal medicines to treat severe malaria were identified. Apart from the anti-malarial fansidar, which was mentioned by 23 in IDIs and 40 in FGDs, participants and informants also frequently mentioned indigenous medicines provided by healers and other respectable herbalists for repelling evil spirits, once a child had severe malaria. Mothers were the important arms for administration of ant-malarial drugs in the villages. Referrals began with healers to CHWs, where no CHWs existed healers directly referred sick children to the health facility. CONCLUSION: Our findings showed that there is a precedent for rectal application of traditional medicine for childhood illness. Therefore rectal artesunate may be a well-received intervention in Nakonde District, provided effective sensitisation, to mothers and CHWs is given which will strengthen the health care delivery system at community level

Differentials of fertility in North and South Gondar zones, northwest Ethiopia: A comparative cross-sectional study

<p>Abstract</p> <p>Background</p> <p>Ethiopia is one of the most densely populated countries in Africa with an estimated population of 77.1 million in mid-2007. Uncontrolled fertility has adversely influenced the socio-economic, demographic and environmental situations of the country. It is one of the largest and poorest countries that, even in the midst of crisis, has maintained high levels of fertility. This study was aimed at investigating the most important factors influencing fertility behavior in Northwest Ethiopia.</p> <p>Methods</p> <p>A comparative cross-sectional study which included 2424 women aged 25 years and above was undertaken in the Amhara region of Northwest Ethiopia. The study subjects were grouped into high fertile and low fertile categories. There were 1011 and 1413 women in the high and low fertile groups, respectively. A multi-stage cluster sampling stratified by place of residence was employed to select the required study subjects. Both bivariate and multivariate logistic regression techniques were used to analyze the data.</p> <p>Results</p> <p>Among the 25 variables considered in this study, only 9 of them were found significantly and independently associated with the level of fertility. Women with at least secondary education were at a lower risk of high fertility with OR = 0.37 (95% CI: 0.21 to 0.64) compared to those with no formal education. However, women with primary education did not show any significant difference when compared with the same baseline group. Age at first marriage was inversely associated with the number of children ever born alive. Place of residence, household expenditure, number of children who have died, attitude towards using contraceptives, women's knowledge on the safe period, and current marital status were the other variables that showed significant associations with the level of fertility.</p> <p>Conclusion</p> <p>Female education beyond the primary level, reduced infant and child mortality, delayed marriage and correct knowledge on the safe period during the menstrual cycle were amongst the main factors that had a bearing on high fertility.</p