Possession and Usage of Insecticidal Bed Nets among the People of Uganda: Is BRAC Uganda Health Programme Pursuing a Pro-Poor Path?

The use of insecticidal bed nets is found to be an effective public health tool for control of malaria, especially for under-five children and pregnant women. BRAC, an indigenous Bangladeshi non-governmental development organization, started working in the East African state of Uganda in June 2006. As part of its efforts to improve the health and well-being of its participants, BRAC Uganda has been distributing long lasting insecticide-treated bed nets (LLIN) at a subsidized price through health volunteers since February 2008. This study was conducted in March-April 2009 to examine how equitable the programme had been in consistence with BRAC Uganda's pro-poor policy

Free distribution of insecticidal bed nets improves possession and preferential use by households and is equitable: findings from two cross-sectional surveys in thirteen malaria endemic districts of Bangladesh

<p>Abstract</p> <p>Background</p> <p>BRAC, an indigenous non-governmental development organization (NGO), has been implementing a programme to prevent and control malaria in the 13 malaria-endemic districts of Bangladesh since 2007. One of the critical preventive interventions is the distribution of insecticidal bed nets (long-lasting insecticide-treated nets, LLINs and insecticide-treated ordinary nets, ITNs) to the community free of cost. This study aimed to assess progress in the possession, preferential use, and knowledge on use of the LLIN/ITNs including the programme's avowed pro-poor inclination one and three and half years after intervention began.</p> <p>Methods</p> <p>A convenient sampling strategy based on malaria endemicity in the districts was adopted. First, thirty <it>upazila </it>(sub-district, with a population around 250,000)<it>s </it>were selected at random, with high prevalent districts contributing more <it>upazilas</it>; second, from each <it>upazila</it>, one (2008) to two (2011) villages (covered by insecticidal bed net distribution programme) were selected. From each village, households that had either one under-five child and/or a pregnant woman were included in the survey, one household being included only once. Data were collected using a pre-tested structured questionnaire.</p> <p>Results</p> <p>In all, 3,760 households in 2008 and 7,895 households in 2011 were surveyed for collecting relevant information. Proportion of households with at least one LLIN, and at least one LLIN/ITN increased (22-59 to 62-67% and 22-64% to 74-76% respectively) over time, including increase in the mean number of LLIN/ITNs per household (≤ 1 to 1 +). The programme achieved > 80% coverage in sleeping under an LLIN/ITN in the case of under-five children and pregnant women, especially in the high-endemic districts. Knowledge regarding critical time of hanging the net also increased over time (7-22 to 44-54%), but remained low. The pro-poor inclination of the programme is reflected in the status of relevant indicators according to self-rated poverty status of the households.</p> <p>Conclusions</p> <p>There has been a substantial improvement in possession and usage of insecticidal bed nets especially for the two most vulnerable groups (under-five children and pregnant women), including a reduction of gaps between the high and low endemic districts, and the deficit and non-deficit households during the study period.</p

Individual, facility and policy level influences on national coverage estimates for intermittent preventive treatment of malaria in pregnancy in Tanzania

BACKGROUND: Delivery of two doses of intermittent preventive treatment of malaria during pregnancy (IPTp) is a key strategy to reduce the burden of malaria in pregnancy in sub-Saharan Africa. However, different settings have reported coverage levels well below the target 80%. Antenatal implementation guidelines in Tanzania recommend IPTp first dose to be given at the second antenatal visit, and second dose at the third visit. This investigation measured coverage of IPTp at national level in Tanzania and examined the role of individual, facility, and policy level influences on achieved coverage. METHODS: Three national household and linked reproductive and child health (RCH) facility surveys were conducted July-August 2005, 2006, and 2007 in 210 clusters sampled using two-stage cluster sampling from 21 randomly selected districts. Female residents who reported a livebirth in the previous year were asked questions about malaria prevention during that pregnancy and individual characteristics including education, pregnancy history, and marital status. The RCH facility serving each cluster was also surveyed, and information collected about drug stocks, health education delivery, and the timing of antenatal care delivery by clinic users. RESULTS: The national IPTp coverage had declined over the survey period being 71% for first dose in 2005 falling to 65% in 2007 (chi2 2.9, p = 0.05), and 38% for second dose in 2005 but 30% in 2007 (chi2 4.4, p = 0.01). There was no evidence of any individual factors being associated with second dose coverage beyond living in an urban area. Availability of sulphadoxine-pyrimethamine at RCH had decreased year on year from 85% of clinics in stock in 2005 to 60% in 2007 (chi2 20.6, p < 0.001). This reduction was evident in rural but not urban clinics. If safety recommendations and national antenatal care guidelines for IPTp delivery were followed, in 2007 only 76% of pregnant women could have received IPTp first dose and only 46% could have received second dose. CONCLUSION: There is scope to improve IPTp first and second dose coverage at national scale within existing systems by improving stock at RCH, and by revising the existing guidelines to recommend delivery of IPTp after quickening, rather than at a pre-defined antenatal visit

Factors Affecting uptake of Optimal Doses of Sulphadoxine-Pyrimethamine for Intermittent Preventive Treatment of Malaria in Pregnancy in Six Districts of Tanzania.

Intermittent preventive treatment during pregnancy (IPTp) with optimal doses (two+) of sulphadoxine-pyrimethamine (SP) protects pregnant women from malaria-related adverse outcomes. This study assesses the extent and predictors of uptake of optimal doses of IPTp-SP in six districts of Tanzania. The data come from a cross-sectional survey of random households conducted in six districts in Tanzania in 2012. A total of 1,267 women, with children aged less than two years and who had sought antenatal care (ANC) at least once during pregnancy, were selected for the current analysis. Data analysis involved the use of Chi-Square (chi2) for associations and multivariate analysis was performed using multinomial logistic regression. Overall, 43.6% and 28.5% of the women received optimal (two+) and partial (one) doses of IPTp-SP respectively during pregnancy. Having had been counseled on the dangers of malaria during pregnancy was the most pervasive determinant of both optimal (RRR = 6.47, 95% CI 4.66-8.97) and partial (RRR = 4.24, 95% CI 3.00-6.00) uptake of IPTp-SP doses. Early ANC initiation was associated with a higher likelihood of uptake of optimal doses of IPTp-SP (RRR = 2.05, 95% CI 1.18-3.57). Also, women with secondary or higher education were almost twice as likely as those who had never been to school to have received optimal SP doses during pregnancy (RRR = 1.93, 95% CI 1.04-3.56). Being married was associated with a 60% decline in the partial uptake of IPTp-SP (RRR = 0.40, 95% CI 0.17-0.96). Inter-district variations in the uptake of both optimal and partial IPTp-SP doses existed (P < 0.05). Counseling to pregnant women on the dangers of malaria in pregnancy and formal education beyond primary school is important to enhance uptake of optimal doses of SP for malaria control in pregnancy in Tanzania. ANC initiation in the first trimester should be promoted to enhance coverage of optimal doses of IPTp-SP. Programmes should aim to curb geographical barriers due to place of residence to enhance optimal coverage IPTp-SP in Tanzania

Determinants of Use of Intermittent Preventive Treatment of Malaria in Pregnancy: Jinja, Uganda

BACKGROUND: Maternal malaria is associated with serious adverse pregnancy outcomes. One recommended means of preventing malaria during pregnancy is intermittent preventive therapy (IPTp) with sulfadoxine/pyrimethamine (SP). We sought to identify determinants of preventive use of SP during pregnancy among recently pregnant women in Uganda. Additionally, we characterized the timing of and indications for the administration of SP at antenatal care (ANC) visits and missed opportunities for SP administration. METHODOLOGY/PRINCIPAL FINDINGS: Utilizing a population-based random sample, we interviewed 500 women living in Jinja, Uganda who had been pregnant in the past year. Thirty-eight percent (192/500) of women received SP for the treatment of malaria and were excluded from the analysis of IPTp-SP. Of the remaining women, 275 (89.3%) reported at least two ANC visits after the first trimester and had an opportunity to receive IPTp-SP according to the Ugandan guidelines, but only 86 (31.3%) of these women received a full two-dose course of IPTp. The remaining 189 (68.7%) women missed one or more doses of IPTp-SP. Among the 168 women that were offered IPTp, 164 (97.6%) of them took the dose of SP. CONCLUSIONS/SIGNIFICANCE: Use of IPTp in Uganda was found to be far below target levels. Our results suggest that women will take SP for IPTp if it is offered during an ANC visit. Missed opportunities to administer IPTp-SP during ANC were common in our study, suggesting provider-level improvements are needed

Knowledge of Malaria and Its Association with Malaria-Related Behaviors—Results from the Malaria Indicator Survey, Ethiopia, 2007

Background: In 2005, the Ministry of Health in Ethiopia launched a major effort to distribute over 20 million long-lasting insecticidal nets, provide universal access to artemisinin-based combination therapy (ACTs), and train 30,000 village-based health extension workers.\ud \ud Methods and Findings: A cross-sectional, nationally representative Malaria Indicator Survey was conducted during the malaria transmission season in 2007. Multivariate logistic regression analyses were performed to assess the effect of women's malaria knowledge on household ITN ownership and women's ITN use. In addition, we investigated the effect of mothers' malaria knowledge on their children under 5 years of age's (U5) ITN use and their access to fever treatment on behalf of their child U5. Malaria knowledge was based on a composite index about the causes, symptoms, danger signs and prevention of malaria. Approximately 67% of women (n = 5,949) and mothers of children U5 (n = 3,447) reported some knowledge of malaria. Women's knowledge of malaria was significantly associated with household ITN ownership (adjusted Odds Ratio [aOR] = 2.1; 95% confidence interval [CI] 1.6–2.7) and with increased ITN use for themselves (aOR = 1.8; 95% CI 1.3–2.5). Knowledge of malaria amongst mothers of children U5 was associated with ITN use for their children U5 (aOR = 1.6; 95% CI 1.1–2.4), but not significantly associated with their children U5 seeking care for a fever. School attendance was a significant factor in women's ITN use (aOR = 2.0; 95% CI 1.1–3.9), their children U5′s ITN use (aOR = 4.4; 95% CI 1.6–12.1), and their children U5 having sought treatment for a fever (aOR = 6.5; 95% CI 1.9–22.9).\ud \ud Conclusions: Along with mass free distribution of ITNs and universal access to ACTs, delivery of targeted malaria educational information to women could improve ITN ownership and use. Efforts to control malaria could be influenced by progress towards broader goals of improving access to education, especially for women

Determinants of Use of Insecticide Treated Nets for the Prevention of Malaria in Pregnancy: Jinja, Uganda

One established means of preventing the adverse consequences of malaria during pregnancy is sleeping under an insecticide treated net (ITN) throughout pregnancy. Despite increased access to this intervention over time, consistent ITN use during pregnancy remains relatively uncommon in sub-Saharan Africa.We sought to identify determinants of ITN use during pregnancy. Utilizing a population-based random sample, we interviewed 500 women living in Jinja, Uganda, who had been pregnant in the past year. ITN ownership at the start of pregnancy was reported by 359 women (72%) and 28 women (20%) acquired an ITN after the first trimester of pregnancy. Among 387 ITN owners, 73% reported either always sleeping under the ITN during all trimesters of pregnancy, or after acquiring their net. Owning more than 1 net was slightly associated with always sleeping under an ITN during pregnancy (RR: 1.13; 95% CI: 1.00, 1.28). Women who always slept under an ITN during pregnancy were more likely to be influenced by an advertisement on the radio/poster than being given an ITN free of charge (RR: 1.48; 95% CI: 1.24, 1.76). No differences were found between other socio-demographic factors, pregnancy history, ANC use or socio-cultural factors.While self-reported ITN ownership and use was common throughout pregnancy, we were unable to pinpoint why a sizable fraction of Ugandan women did not always adhere to recommendations for use of an ITN during pregnancy. More data are needed on the capacity of individual households to support the installation of ITNs which may provide insight into interventions targeted at improving the convenience and adherence of daily ITN use

Barriers to the effective treatment and prevention of malaria in Africa: A systematic review of qualitative studies

<p>Abstract</p> <p>Background</p> <p>In Africa, an estimated 300-500 million cases of malaria occur each year resulting in approximately 1 million deaths. More than 90% of these are in children under 5 years of age. To identify commonly held beliefs about malaria that might present barriers to its successful treatment and prevention, we conducted a systematic review of qualitative studies examining beliefs and practices concerning malaria in sub-Saharan African countries.</p> <p>Methods</p> <p>We searched Medline and Scopus (1966-2009) and identified 39 studies that employed qualitative methods (focus groups and interviews) to examine the knowledge, attitudes, and practices of people living in African countries where malaria is endemic. Data were extracted relating to study characteristics, and themes pertaining to barriers to malaria treatment and prevention.</p> <p>Results</p> <p>The majority of studies were conducted in rural areas, and focused mostly or entirely on children. Major barriers to prevention reported included a lack of understanding of the cause and transmission of malaria (29/39), the belief that malaria cannot be prevented (7/39), and the use of ineffective prevention measures (12/39). Thirty-seven of 39 articles identified barriers to malaria treatment, including concerns about the safety and efficacy of conventional medicines (15/39), logistical obstacles, and reliance on traditional remedies. Specific barriers to the treatment of childhood malaria identified included the belief that a child with convulsions could die if given an injection or taken to hospital (10/39).</p> <p>Conclusion</p> <p>These findings suggest that large-scale malaria prevention and treatment programs must account for the social and cultural contexts in which they are deployed. Further quantitative research should be undertaken to more precisely measure the impact of the themes uncovered by this exploratory analysis.</p

The combined effect of determinants on coverage of intermittent preventive treatment of malaria during pregnancy in the Kilombero Valley, Tanzania

BACKGROUND\ud \ud Intermittent preventive treatment during pregnancy (IPTp) at routine antenatal care (ANC) clinics is an important and efficacious intervention to reduce adverse health outcomes of malaria infections during pregnancy. However, coverage for the recommended two IPTp doses is still far below the 80% target in Tanzania. This paper investigates the combined impact of pregnant women's timing of ANC attendance, health workers' IPTp delivery and different delivery schedules of national IPTp guidelines on IPTp coverage.\ud \ud METHODS\ud \ud Data on pregnant women's ANC attendance and health workers' IPTp delivery were collected from ANC card records during structured exit interviews with ANC attendees and through semi-structured interviews with health workers in south-eastern Tanzania. Women's timing of ANC visits and health worker's timing of IPTp delivery were analyzed in relation to the different national IPTp schedules and the outcome on IPTp coverage was modelled.\ud \ud RESULTS\ud \ud Among all women eligible for IPTp, 79% received a first dose of IPTp and 27% were given a second dose. Although pregnant women initiated ANC attendance late, their timing was in line with the national guidelines recommending IPTp delivery between 20-24 weeks and 28-32 weeks of gestation. Only 15% of the women delayed to the extent of being too late to be eligible for a first dose of IPTp. Less than 1% of women started ANC attendance after 32 weeks of gestation. During the second IPTp delivery period health workers delivered IPTp to significantly less women than during the first one (55% vs. 73%) contributing to low second dose coverage. Simplified IPTp guidelines for front-line health workers as recommended by WHO could lead to a 20 percentage point increase in IPTp coverage.\ud \ud CONCLUSIONS\ud \ud This study suggests that facility and policy factors are greater barriers to IPTp coverage than women's timing of ANC attendance. To maximize the benefit of the IPTp intervention, revision of existing guidelines is needed. Training on simplified IPTp messages should be consolidated as part of the extended antenatal care training to change health workers' delivery practices and increase IPTp coverage. Pregnant women's knowledge about IPTp and the risks of malaria during pregnancy should be enhanced as well as their ability and power to demand IPTp and other ANC services

Prospects, achievements, challenges and opportunities for scaling-up malaria chemoprevention in pregnancy in Tanzania: the perspective of national level officers

OBJECTIVES: To describe the prospects, achievements, challenges and opportunities for implementing intermittent preventive treatment for malaria in pregnancy (IPTp) in Tanzania in light of national antenatal care (ANC) guidelines and ability of service providers to comply with them. METHODS: In-depth interviews were made with national level malaria control officers in 2006 and 2007. Data was analysed manually using a qualitative content analysis approach. RESULTS: IPTp has been under implementation countrywide since 2001 and the 2005 evaluation report showed increased coverage of women taking two doses of IPTp from 29% to 65% between 2001 and 2007. This achievement was acknowledged, however, several challenges were noted including (i) the national antenatal care (ANC) guidelines emphasizing two IPTp doses during a woman's pregnancy, while other agencies operating at district level were recommending three doses, this confuses frontline health workers (HWs); (ii) focused ANC guidelines have been revised, but printing and distribution to districts has often been delayed; (iii) reports from district management teams demonstrate constraints related to women's late booking, understaffing, inadequate skills of most HWs and their poor motivation. Other problems were unreliable supply of free SP at private clinics, clean and safe water shortage at many government ANC clinics limiting direct observation treatment and occasionally pregnant women asked to pay for ANC services. Finally, supervision of peripheral health facilities has been inadequate and national guidelines on district budgeting for health services have been inflexible. IPTp coverage is generally low partly because IPTp is not systematically enforced like programmes on immunization, tuberculosis, leprosy and other infectious diseases. Necessary concerted efforts towards fostering uptake and coverage of two IPTp doses were emphasized by the national level officers, who called for further action including operational health systems research to understand challenges and suggest ways forward for effective implementation and high coverage of IPTp. CONCLUSION: The benefit of IPTp is appreciated by national level officers who are encouraged by trends in the coverage of IPTp doses. However, their appeal for concerted efforts towards IPTp scaling-up through rectifying the systemic constraints and operational research is important and supported by suggestions by other authors