Design, Implementation, and Evaluation of a School Insecticide-Treated Net Distribution Program in Cross River State, Nigeria.

Angela Acosta,Iyam Ugot,Richmond Ato Selby,Lilia Gerberg,George Greer,Jessica Kafuko,Abidemi Okechukwu,Hannah Koenker,Matthew Lynch,Megan Fotheringham,Albert Kilian,Mark Maire,Kassahun Belay,Emmanuel Obi,Uwem Inyang

doi:10.9745/ghsp-d-17-00350

Abstract

In 2013, the World Health Organization recommended distribution through schools, health facilities, community health workers, and mass campaigns to maintain coverage with insecticide-treated nets (ITNs). We piloted school distribution in 3 local government areas (LGAs) of Cross River State, Nigeria. From January to March 2011, all 3 study sites participated in a mass ITN campaign. Baseline data were collected in June 2012 (N=753 households) and school distribution began afterward. One ITN per student was distributed to 4 grades once a year in public schools. Obubra LGA distributed ITNs in 2012, 2013, and 2014 and Ogoja LGA in 2013 and 2014 while Ikom LGA served as a comparison site. Pregnant women in all sites were eligible to receive ITNs through standard antenatal care (ANC). Endline survey data (N=1,450 households) were collected in March 2014. Data on ITN ownership, population access to an ITN, and ITN use were gathered and analyzed. Statistical analysis used contingency tables and chi-squared tests for univariate analysis, and a concentration index was calculated to assess equity in ITN ownership. Between baseline and endline, household ownership of at least 1 ITN increased in the intervention sites, from 50% (95% confidence interval [CI]: 44.7, 54.3) to 76% (95% CI: 71.2, 81.0) in Ogoja and from 51% (95% CI: 35.3, 66.7) to 78% (95% CI: 71.5, 83.1) in Obubra, as did population access to ITN, from 36% (95% CI: 32.0, 39.5) to 53% (95% CI: 48.0, 58.0) in Ogoja and from 34% (95% CI: 23.2, 45.6) to 55% in Obubra (95% CI: 48.4, 60.9). In contrast, ITN ownership declined in the comparison site, from 64% (95% CI: 56.4, 70.8) to 43% (95% CI: 37.4, 49.4), as did population ITN access, from 47% (95% CI: 40.0, 53.7) to 26% (95% CI: 21.9, 29.9). Ownership of school ITNs was nearly as equitable (concentration index 0.06 [95% CI: 0.02, 0.11]) as for campaign ITNs (-0.03 [95% CI: -0.08, 0.02]), and there was no significant oversupply or undersupply among households with ITNs. Schools were the most common source of ITNs at endline and very few households (<2%) had nets from both school and ANC. ITN distribution through schools and ANC provide complementary reach and can play an effective role in achieving and maintaining universal coverage. More research is needed to evaluate the cost-effectiveness of such continuous distribution channels in combination with, or as a potential replacement for, subsequent mass campaigns.

Highlights

In 2013, the World Health Organization recommended distribution through schools, health facilities, community health workers, and mass campaigns to maintain coverage with insecticide-treated nets (ITNs)
ITN ownership declined in the comparison site, from 64% to 43%, as did population ITN access, from 47% to
More research is needed to evaluate the cost-effectiveness of such continuous distribution channels in combination with, or as a potential replacement for, subsequent a Johns Hopkins Center for Communication Programs, Baltimore, MD, USA. b Tropical Health, LLP, Montagut, Spain. c Malaria Consortium, Abuja, Nigeria. d Malaria Consortium, Kampala, Uganda. e Office of the Governor, Cross River State, Nigeria. f Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA. g U.S President's Malaria Initiative, U.S Agency for International Development, Abuja, Nigeria. h U.S President's Malaria Initiative, U.S Agency for International Development, Dar es Salaam, Tanzania. i U.S President's Malaria Initiative, U.S Agency for International Development, Bureau for Global Health, Office of Health, Infectious Disease & Nutrition, Washington, DC, USA

Summary

Introduction

In 2013, the World Health Organization recommended distribution through schools, health facilities, community health workers, and mass campaigns to maintain coverage with insecticide-treated nets (ITNs). Over the past 10 years, hundreds of millions of ITNs have been distributed throughout sub-Saharan Africa.[1] Most of these have been through either targeted or universal mass campaigns, which have been found to raise coverage rapidly and equitably.[2,3,4,5] maintaining these gains can be a challenge. Countries have used mass campaigns to replenish ITN coverage every few years. These “top-up” and repeated universal coverage campaigns can be challenging and costly, given the burden of conducting registration visits to every household and the potential for oversupply. Most households cannot obtain ITNs between mass campaigns.[6,7] antenatal care (ANC) clinics, the Expanded Program on Immunization (EPI), and retailers distribute or sell ITNs, the volumes are too low to maintain universal coverage.[8]

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Results

Discussion

Conclusion