Abstract
BackgroundMalaria remains one of the largest public health problems facing the developing world. Insecticide-treated nets (ITNs) are an effective intervention against malaria. ITN delivery through routine health services, such as antenatal care (ANC) and childhood vaccination (EPI), is a promising channel of delivery to reach individuals with the highest risk (pregnant women and children under five years old). Decisions on whether to deliver ITNs through both channels depends upon the reach of each of these systems, whether these are independent and the effectiveness and cost effectiveness of each. Predictors of women attending ANC and EPI separately have been studied, but the predictors of those who attend neither service have not been identified.MethodsData from Chad, Mali and Niger demographic and health surveys (DHS) were analyzed to determine risk factors for attending neither service. A conceptual framework for preventative health care-seeking behaviour was created to illustrate the hierarchical relationships between the potential risk factors. The independence of attending both ANC and EPI was investigated. A multivariate model of predictors for non-attendance was developed using logistic regression.ResultsANC and EPI attendance were found to be strongly associated in all three countries. However, 47% of mothers in Chad, 12% in Mali and 36% in Niger did not attend either ANC or EPI. Region, mother's education and partner's education were predictors of non-attendance in all three countries. Wealth index, ethnicity, and occupation were associated with non-attendance in Mali and Niger. Other predictors included religion, healthcare autonomy, household size and number of children under five.ConclusionsAttendance of ANC and EPI are not independent and therefore the majority of pregnant women in these countries will have the opportunity to receive ITNs through both services. Although attendance at ANC and EPI are not independent, delivery through both systems may still add incrementally to delivery through one alone. Therefore, there is potential to increase the proportion of women and children receiving ITNs by delivering through both of these channels. However, modelling is required to determine the level of attendance and incremental potential at which it's cost effective to deliver through both services.
Highlights
Malaria remains one of the largest public health problems facing the developing world
Of the women who attended neither antenatal care (ANC) nor expanded programme on immunization (EPI), 32% of women were in the poorest wealth quintile, 82% worked in agriculture, 93% had no education, 50% were between 20 and 29 years old and 30% were from southern regions
The findings show that attendance at ANC and attendance at EPI are not independent, that is women that attend ANC are more likely to take their child to EPI than women that do not attend ANC, or children taken to EPI are more likely to have mothers that attended ANC
Summary
Malaria remains one of the largest public health problems facing the developing world. ITN delivery through routine health services, such as antenatal care (ANC) and childhood vaccination (EPI), is a promising channel of delivery to reach individuals with the highest risk (pregnant women and children under five years old). Eighty-five percent of malaria cases and 90% of malaria deaths occur in Africa, with pregnant women and children under five years being especially at risk [1]. ITNs are a simple, effective and cost-effective malaria intervention that can reduce incidence of clinical malaria by at least 50% and save 5.5 lives for every 1000 children under five years old protected with an ITN per year [3]; use of an ITN during pregnancy reduces low birth weight, maternal anaemia and risk of miscarriage [4]. The World Health Organization (WHO) recommends a combination strategy of “catch up” and “keep up” activities to achieve and maintain sustainable universal ITN ownership and use [5]
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