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What are the effects of strategies to increase possession and use of insecticide-treated bednets to prevent malaria?

Malaria is a life-threatening parasitic disease that affects approximately 40% of the world’s population (mostly in the poorest countries). Insecticide-treated bednets effectively prevent malaria. However, cost and other barriers can hinder possession and use of insecticide-treated bednets. Strategies to increase possession and use include providing bednets for free or reducing the cost, education about appropriate use of bednets, and providing incentives to encourage use of bednets.

Malaria is a life-threatening parasitic disease that affects approximately 40% of the world’s population (mostly in the poorest countries). Insecticide-treated bednets effectively prevent malaria. However, cost and other barriers can hinder possession and use of insecticide-treated bednets. Strategies to increase possession and use include providing bednets for free or reducing the cost, education about appropriate use of bednets, and providing incentives to encourage use of bednets.

 

Key messages

 

  • Providing free insecticide-treated bednets compared to providing subsidised or full market price bednets probably in-creases the number of pregnant women, adults and children who possess insecticide-treated bednets, but probably leads to little or no difference in appropriate use of bednets.
  • Education about appropriate use of insecticide-treated bed-nets may increase the number of adults and children under five sleeping under bednets.
  • Providing incentives to encourage the use of insecticide-treated bednets may lead to little or no difference in use.
  • The included studies were conducted in rural communities in Africa, India and Iran.

Background

One of the barriers to owning and using insecticide-treated bednets is their cost. Populations affected by malaria are among the poorest in the world and they may not be able to afford insecticide-treated bednets. Wealth, living in an urban rather than rural area, and higher levels of education are other important factors positively associated with insecticide-treated bednet possession and use. Not knowing how to use bednets appropriately can also be a barrier to using them.



About the systematic review underlying this summary

Review objectives: To assess the evidence on the effectiveness and equity of strategies to increase ownership and proper use of insecticide-treated bednets (ITNs).
Type of What the review authors searched for What the review authors found
Study designs & interventions Randomised trials, non-randomised trials, controlled before-after studies and interrupted time series studies evaluating interventions to increase ITN ownership and use

Ten randomised trials: four studies used a

combination of strategies focusing on ITN delivery to increase ITN ownership and appropriate ITN use; two studies focused on ITN delivery strategies only; and seven studies examined appropriate use strategies
Participants

Individuals (children and adults) in

malaria endemic areas

 

Adults, children under five years, pregnant women, mothers of children under five years, rural cotton farmers
Settings Not specified Rural communities in Africa, India, and Iran
Outcomes ITN ownership, ITN use and a range of secondary outcomes including (among others) equity ratio of household ITN ownership and adverse effects

ITN ownership, ITN use, and malaria

morbidity
Date of most recent search: February 2013
Limitations: This was a well-conducted review with only minor limitations

Augustincic Polec L, Petkovic J, Welch V, et al. Strategies to increase the ownership and use of insecticide-treated bednets to prevent malaria. Cochrane Database Syst Rev 2015; 3: CD009186.

Summary of findings

The review included ten studies evaluating interventions to increase insecticide treated bednet possession and use. All the studies were conducted in rural communities in Africa, India and Iran.

 

1) Free insecticide-treated bednets compared to insecticide treated bednets at any cost for malaria prevention

Free distribution entails the provision of free insecticide-treated bednets at selected points of care, such as antenatal clinics, and mass campaigns of regional or national provision, usual-ly in tandem with other health interventions.

 

 

  • Providing free insecticide-treated bednets compared to providing subsidized or full market price bednets
  • Probably increases the number of pregnant women, adults and children who possess insecticide-treated bednets, but probably leads to little or no difference in use of bednets. The certainty of this evidence is moderate.

 

 

Distributing insecticide-treated bednets (ITNs) free compared to making ITNs available for purchase 

People:  Adults (including pregnant women) and children
Settings
:  Rural communities
Intervention
: Free ITN (with or without social marketing)
Comparison
: ITN at any cost (with or without social marketing)
Outcomes Impact Certainty of the evidence
(GRADE)
ITN possession among pregnant women, adults and children
Free ITN distribution probably increases the number of pregnant women, adults and children who possess ITNs compared to providing subsidized ITNs or ITNs offered at full market price

Moderate

Appropriate use
Free ITN distribution probably leads to little or no difference in use of ITNs compared to providing subsidized ITNs or ITNs offered at full market price.

Moderate

GRADE: GRADE Working Group grades of evidence (see above and last page)

2) Education about appropriate insecticide treated bednet use compared with no education

Different educational methods were used (e.g. training for household heads, house to house visits to teach how to properly hang and use insecticide treated bednets, educational bro-chures).

Education about appropriate use of insecticide-treated bednets

 

  • May increase the number of adults and children under five sleeping under bednets. The certainty of this evidence is low.

Education about appropriate insecticide-treated bednet (ITN) use compared with no education

People:  Adults (including pregnant women) and children
Settings
:  Rural communities
Intervention
: Education about appropriate ITN use
Comparison
: No education about appropriate ITN use
Outcomes Impact Certainty of the evidence
(GRADE)
ITN use by adults (any ITN use)
Education may increase the number of adults using ITNs (including sleeping under ITNs).

Low

ITN use by children under 5
Education may increase the number of children under 5 years old using ITNs (including sleeping under ITNs).

Low
GRADE: GRADE Working Group grades of evidence (see above and last page)

3) Providing incentives to encourage insecticide treated bednet use compared with no incentives

An undisclosed prize was promised for appropriate use of insecticide treated bednets to gether with a voucher compared to a bednet voucher and no prize in a study in rural Madagascar.

Providing incentives to encourage the use of insecticide treated bednets

 

  • May lead to little or no difference in use. The certainty of this evidence is low.

Providing incentives to encourage insecticide-treated bednet (ITN) use compared to no incentives

People:  Households
Settings
:  Rural communities
Intervention
: Providing incentives to encourage ITN use
Comparison
: Not providing incentives to encourage ITN use
Outcomes Impact Certainty of the evidence
(GRADE)
Use (net mounted)
Providing incentives (a prize) to encourage ITN use may lead to little or no difference in ITN use compared to not providing incentives.

Low

GRADE: GRADE Working Group grades of evidence (see above and last page)

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY
All the included studies were conducted in resource poor settings (rural communities in Africa, India, and Iran). 

The review findings are directly applicable to low income countries.

 

  • Similar effects are likely, given comparable health systems and baseline condtions, such as malaria prevalence and insecticide-treated bednet delivery mechanisms.

 


EQUITY

Providing free insecticide treated bednets and education improved possession and appropriate use of insecticide treated bednets among vulnerable populations (pregnant women, under five children, low income populations, rural communities).

 

 

  • Insecticide treated bednet possession increased with decreasing cost.

 


Providing free insecticide-treated bednets and education may reduce health inequities by increasing access and use of insecticide-treated bednets among disadvantaged groups most vulnerable to malaria.
ECONOMIC CONSIDERATIONS
Five studies evaluated the effect of insecticide-treated bednet price on possession and found that possession decreased with increasing price.

Strategies achieving high possession and use of insecticide treated bednets are those which are free or those which deliver insecticide treated bednets at a very low cost. Scaling up such strategies might require substantial subsidies/resource allocation.

 

 

  • Effective strategies are likely to reduce costs associated with malaria.

 


MONITORING & EVALUATION

None of the included studies examined the adverse microeconomic effects of interventions providing free or subsidized insecticide-treated bednets to the community. 


Potential adverse effects of interventions providing free or subsidized insecticide treated bednets should be monitored alongside impacts on clinical outcomes such as malaria related morbidity and mortality.

 

 

  • Use of insecticide treated bednets should be monitored, since in some areas possession has been found to be high but use low.

 


*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm

 

Additional information

Related literature

Willey BA, Smith Paintain L, Mangham L, Car J, Armstrong Schellenberg J. Strategies for delivering insecticide-treated nets at scale for malaria control: a systematic review. Bull of the WHO 2012; 90:633-712.

 

Sexton, AR. Best practices for an insecticide-treated bed net distribution program in sub-Saharan eastern Africa. Malaria Journal 2011; 10:57.

 

Lengeler C. Insecticide-treated bed nets and curtains for preventing malaria. Cochrane Database Syst Rev 2004; 2:CD000363.

 

This summary was prepared by

Newton Opiyo, KEMRI-Wellcome Trust Research Programme, Kenya.

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Lana Augustincic Polec, Xavier Bosch-Capblanch, and Paul Garner.

 

This review should be cited as

Augustincic Polec L, Petkovic J, Welch V, et al. Strategies to increase the ownership and use of insecticide-treated bednets to prevent malaria. Cochrane Database Syst Rev 2015; 3: CD009186.

 

The summary should be cited as

Opiyo N. What are the effects of strategies to increase possession and use of insecticide-treated bednets to prevent malaria? A SUPPORT Summary of a sys-tematic review. February 2017. www.supportsummaries.org

 

Keywords

evidence-informed health policy, evidence-based, systematic review, health sys-tems research, health care, insecticide-treated bednets, malaria, low and middle-income countries, developing countries,

primary health care



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