rapid coverage assessment of long-lasting … · 23.12.2014 · • dr. thaung hlaing, deputy...

[1]

RAPID COVERAGE ASSESSMENT OF LONG-LASTING

INSECTICIDE TREATED NETS IN MYANMAR

Authors: Malaria Consortium

Assessment Design: Malaria Consortium and Save the Children- Myanmar

Data Collection: Save the Children, Myanmar

Analysis and Report: Celine Zegers de Beyl, M&E Specialist, Malaria Consortium

Johns Hopkins Bloomberg School of Public Health Center for Communication Programs

Malaria Consortium

December 2014

Cooperative Agreement # GHS-A-00-09-00014-00

RESEARCH REPORT

Rapid Coverage Assessment of LLIN in Myanmar, NetWorks Project [2]

List of Abbreviations

BCC Behaviour Change Communication

CAP Malaria Control and Prevention of Malaria Project

CHG Community Health Group

DMR-LM Department of Medical Research – Lower Myanmar

HH Households

HoH Head of Household

IRB Institutional Review Board

ITN Insecticide Treated Nets

JHUCCP Center for Communication Programs at John Hopkins University

LLIN Long Lasting Insecticide treated mosquito Nets

MC

RBM

Malaria Consortium

Roll Back Malaria

SCI Save the Children International

URC University Research Center

USAID

PMI

United States Agency for International Development

President’s Malaria Initiative

VBDC Vector Borne Disease Control

VMW Volunteer Malaria Worker


Table of Contents

List of Abbreviations .............................................................................................................................................................. 1

Acknowledgements ............................................................................................................................................................... 4

Abstract ................................................................................................................................................................................... 5

Introduction ............................................................................................................................................................................ 6

Background ........................................................................................................................................................................ 6

Study aims and objectives ................................................................................................................................................. 9

Methods ................................................................................................................................................................................ 10

Sampling and sample size ................................................................................................................................................. 10

Data collection .................................................................................................................................................................. 10

Data processing, entry and analysis .................................................................................................................................. 11

Ethical considerations........................................................................................................................................................ 11

Results ................................................................................................................................................................................... 12

Discussion ............................................................................................................................................................................. 19

Conclusion ........................................................................................................................................................................ 20

References ............................................................................................................................................................................ 22

Annex .................................................................................................................................................................................... 23


Acknowledgements

This study was made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of USAID/JHU Cooperative Agreement No. GHS-A‐00‐09-00014-00. The contents are the responsibility of Malaria Consortium and do not necessarily reflect the views of USAID or the United States Government.

A team assisted in the preparation of this report. Thank you to the following individuals for their contributions (alphabetically):

• Adelaida Degregorio, Programme Manager, CAP-Malaria

• Dr. Phone Si Hein, Deputy Programme Manager, CAP-Malaria

• Dr. Thaung Hlaing, Deputy Director(Malaria), Programme Manager ( National Malaria Control Programme)

• Dr. Htwe Htwe Htet, Technical Assistant, Malaria Consortium

• Dr. Myat Phone Kyaw, Deputy Director General, Department of Medical Research, Lower Myanmar

• Dr. Thae Maung Maung, Research Officer, Department of Medical Research, Lower Myanmar

• Yasmin Padamsee-Forbes, Country Representative, Malaria Consortium

• Dr. Arantxa Roca, Asia Technical Director, Malaria Consortium

• Dr. Johannah Wegerdt, Consultant

• Hlaing Yin Win, M&E Officer, CAP-Malaria

• Dr. Celine Zegers de Beyl, M&E Specialist, Malaria Consortium


Abstract

Background: Approximately 35,000 long lasting insecticide treated mosquito nets (LLIN) were distributed in Myanmar between March and July 2013 by the PMI-funded CAP Malaria Project through Save the Children International (as URC’s country partner). The target areas included 4 townships in Kayin State. The campaign objective was to reach universal coverage (i.e. 1 LLIN for every 2 people). The distribution happened in two phases. All LLINs were distributed free of charge. Methods: The distribution was evaluated through a representative cross-sectional household interview survey with a stratified two stage cluster sampling design. The target sample size was therefore 480 households in 30 clusters. Data were collected 9 to 12 months after the distribution. Data were collected using a standard questionnaire. Results: 97.3% of households received a LLIN from the campaign and 98.9% owned at least one LLIN on the survey day. An average of 2.27 LLIN was distributed to households who benefited from the campaign (2.61 in Phase 1 vs. 1.94 in Phase 2). Overall, 43.3% owned 1 LLIN for 2 people (57.0% in Phase 1 vs. 29.6% in Phase 2). Out of all households, 43.8% had all members using an LLIN the previous night (32.9% in Phase 1 vs. 54.8% in Phase 2). Conclusion: The campaign was effective in reaching households. However, households in Phase 1 tended to be oversupplied with LLINs while households in Phase 2 villages were more likely to be undersupplied at the time of the survey. While LLIN use the night before the survey fell short of the 80% RBM target, a “net culture” was successfully introduced. This report recommends 1/ piloting a continuous distribution system so households can acquire new LLIN, when necessary, based on their own needs; 2/ strengthening the behaviour change communication component and 3/ strengthening the M&E plan to generate robust evidence for decision making.


Introduction

Background

a. Context Consistent use of long lasting insecticide treated nets (LLIN) is recognized as one of the most effective ways to prevent malaria and therefore WHO recommends universal coverage for all people at risk of malaria (WHO, 2013). A sustained high coverage of LLINs results in the reduction of the mosquito density and thus in the reduction of overall malaria transmission by a systematic distribution or LLINs, along with information on how to hang, use and maintain them properly (WHO guidance, 2013). LLIN distribution through mass campaign is acknowledged as the best strategy to rapidly achieve high coverage. However, soon after the distribution, the coverage gradually decreases almost instantly due to net deterioration, loss of nets, and population growth, and particularly in the case of Kayin State, population movement. Therefore, complementary continuous distribution channels are required to maintain the gains from mass campaigns. The Control and Prevention of Malaria Project (CAP Malaria Project) in Myanmar is a regional project implemented in the Mekong sub-region countries of Myanmar, Cambodia, and Thailand, by the University Research Center (URC) together with country partners with funding from the President's Malaria Initiative (PMI). The project aims at assisting National Vector Borne Disease Control programmes in containing the spread of multi-drug resistant Plasmodium falciparum malaria in the Greater Mekong Sub-region. LLIN distribution to reach universal coverage is a key element for the prevention of transmission of resistant parasite.

b. Target population Kayin State is an administrative division of Myanmar, also known as Karen State, located at the Thai Myanmar border. It is divided into seven townships. In Kayin State, the project is being implemented in Hpa-An, Hlaing bwe, Kawkareik and Myawaddy townships by Save the Children International (SCI-Myanmar) and its’ local NGO partner – MHAA (Myanmar Health Assistant Association). LLIN distribution and behaviour change communication (BCC) are some of the key activities related to the project’s intervention on vector control to prevent transmission. As these four townships are located very close to Thai border, the probability of transmission of resistant parasite via migrant workers and mobile population from those areas is high. These four townships cover a population of about 71,000 people, living in hard-to-reach or remote communities, with limited access to health care services.


Figure 1: Kayin State

c. LLIN distribution Approximately 35,000 LLINs were distributed in Myanmar between February and June 2013 by the CAP Malaria Project through Save the Children International (as URC’s country partner). The target areas included 4 townships in Kayin State and the distribution was implemented in two phases: Phase 1: Hpa-An, Hlaingbwe, and Kawkareik Townships, covering 101 villages with a total covered population of 57,000

from February to April 2013 Phase 2: Myawaddy Township, covering 33 villages and approximately 14,000 people from April to June 2013

The campaign objective was to reach universal coverage, here defined as one LLIN for every two persons. All LLINs were distributed free of charge. Prior to the distribution, a process of house-to-house registration was conducted in October-November 2012 to:

1) Identify the total population and households in each village (i.e. mini census),

Map


2) Count the number of existing and usable LLIN already present in each household, and

3) Calculate the gap to reach universal coverage or the corresponding number of LLINs that should be given to each household. The number of nets needed for each family was written on HH LLIN cards.

4) LLIN were then delivered to households at fixed-point distribution sites. On additional nets was provided to each forest dweller.

The field teams were supported by the Community Health Group (CHG) members and Volunteer Malaria Worker (VMW) of each village to gather the household representatives in a central community point during the LLIN distribution, and they also helped ensure the orderly manner of the LLIN distribution process. The LLIN distribution was complemented by a BCC component to promote LLIN use and other malaria prevention messages among the population through BCC materials such as pamphlets, posters, and booklets that were distributed to all households during LLIN distribution.

Towards the end of these two phases, additional LLINs were distributed to migrant and mobile workers (not from targeted villages) in the same four townships, for Malaria Week celebrations held from June to July 2013. CAP Malaria provided one LLIN package (50 LLIN) to the CHG members of the village to deliver immediately to any new comers/ migrants.

In addition, teams distributed 1,104 LLINs during World Malaria Day/ National Malaria Week Celebrations to people working in the forest during a Top-up campaign.

This report provides information on field based assessments that were conducted in March 2014.


Figure 2: Timeline of activities

2012 2013 2014

Aug Sept Oct Nov Dec Jan Feb Mar Apr May June Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May

Mini census Endline surveyTop up LLIN campaign

Phase 2(1 Township)

Phase 1(3 Townships)

Study aims and objectives

This rapid survey was conducted to estimate the effectiveness of the LLIN distribution campaign. The specific objectives included:

1. Measure LLIN ownership after the campaign 2. Measure LLIN use among the population and vulnerable groups such as young children and people working in

the forest 3. Compare the coverage achieved in phase 1 and phase 2


Methods

Sampling and sample size

This was a cross-sectional household interview survey with a stratified two stage cluster sampling design. Stratum was defined as phase of distribution and clusters as villages (communities). The following townships targeted in Phase 1: Hpa-An, Hlaingbwe, and Kawkareik. The remaining township constituted phase 2 (Myawaddy). The sampling procedure was specifically designed to obtain a representative sample of the population and allow the inclusion of any community or household that potentially omitted during the LLIN distribution activities.

The expected coverage for the latest LLIN distribution campaign (phase 2) was assumed to be 90% (e.g. 90% of interviewed households with one LLIN per every two people). For the targeted population in the Phase 1 campaign, it was assumed that approximately 70% (slightly lower due potentially to involuntary loss of the net or physical deterioration of the net). In these districts, 70% coverage was considered to be of public health importance as an alternative distribution strategy (such as continuous distribution) might be required in this population if rapid loss is detected.

Given that it is logistically challenging to conduct a survey using a simple random sample of households from all targeted areas in the country, a stratified multi-stage cluster sampling approach was used. The selection of villages in each strata was done using probability proportionate to size (PPS) where villages with more households got more chance of being selected compared to those with fewer households. Using this method, 15 villages were randomly selected in strata 1, and 15 villages in strata 2. On each selected village, 16 households were selected from the listing using simple random technique. Note that only villages targeted in the distribution campaigns were included in this evaluation.

Therefore, assuming an overall LLIN coverage of 80%, 1.75 design effect, 10% non-response rate and a precision of 0.05, a total of 493 households (HH) (e.g. 30 clusters of 16HH/cluster) would be required (~15 clusters/~250HH per strata). This sample size was estimated to allow detection of differences between the 2 strata (e.g. 90% vs. 70% coverage) with 90% power. The target sample size was therefore 480 households in 30 clusters.

Data collection The study conducted personal interviews with heads of households (HoH) or the alternative head of household at the time of the interview. A simple questionnaire was administered to collect information to assess whether enough nets were distributed during the campaign (see Annex 1). An important aspect was to identify reasons for potentially not reaching the target of one net for two people during distribution. The questionnaire was developed based on a similar tool designed for an assessment conducted by Malaria Consortium in Cambodia (Malaria Consortium; 2012). The Informed Consent form and the Questionnaire were translated into local language. All translations were certified independently.

The teams were trained over three days and a morning was spent piloting the tools in nearby villages and revised accordingly. Training involved informing them of the project and training on methods of data collection, definitions and conduct. The teams were shown a PowerNet during training, which was the distinct brand used in the


distribution and easy to identify as they are Blue in color and some would still have a CAP Malaria and PMI label-stickers attached into their corner hanger rings prior to distribution (although this cannot be assured anymore after 10-12 months).

Each team from Save the Children and Malaria Consortium consisted of two people (supervisor and interviewer) plus one local worker (the village health worker or local authority) to guide the team, translate where necessary from Myanmar to Karen, and introduce the team to the heads of household to be interviewed. Each team was assigned to 2-3 villages.

Data collection teams were dispatched to the four townships; Hlaingbwe, Hpa-An, Kawkareik and Myawaddy, to conduct interviews. When they entered the pre-selected village, they introduced themselves and the assessment to the village leader. If a selected household was empty (no respondent available at the time of interview), this visit attempt was recorded and an additional household was randomly selected and interviewed. At each household, the team requested to speak to the female head of the household, over the age of 18. If no female respondent was available, a male respondent over the age of 18 was interviewed instead. The team introduced themselves and obtained written informed consent before proceeding. Interviews took approximately 10-15 minutes to complete. Data collection started in Pha-an, Hlaingbwe and Myawaddy on the 12th March 2014 and in Kawkareik on 18th March 2014; all data collection was completed by 21st March 2014.

Data processing, entry and analysis All data was double entered using Epi data software version 3.1 and took approximately 2 weeks to complete. Both data sets were then compared and any discrepant record was verified from the original questionnaires. Once this first stage of cleaning was finished the data set was transferred to Stata Statistical 13.0 software package for further consistency checks and preparation of data files for analysis. The final data file was sent to the evaluation team for further cleaning. In analysis, descriptive statistics was mainly used and main outcomes were described by percentage. All analysis accounted for sampling design and weights using the “svy” family commands in Stata. This was done to ensure the estimate were the closest possible to the real proportions in the population. The following key indicators were estimated: o proportion of households with at least one ITN o proportion of households with “enough” ITN (one ITNs per every two people or better) o proportion of de-facto residents with access to ITN within household o proportion of de-facto residents that slept under an ITN the night preceding the survey

Ethical considerations Individual verbal informed consent was sought from all respondents before interviews were conducted. Before each interviewee was asked to give consent, the interviewer gave a brief description of the assessment objectives, the data collection procedure, the potential harm to participants, the expected benefits, and the voluntary nature of participation. In addition, consent was also sought from community representatives (chiefs). Participants were assured that data would be kept confidential and would not be shared with non-project staff. Participants in the final data set were rendered anonymous by removing the variable “name” and all other information within a particular cluster that could help to identify individuals or households, and replacing these with a new numerical identification number


generated to uniquely identify the individuals and the households. The tools were reviewed and approved by both the JHUCCP (IRB No. 5417) and the Myanmar DMR ethical Institutional Review Boards (IRB). Issue to consider for the interpretation of the results

Five communities were excluded at the sampling stage before fieldwork started and replaced using the sampling procedure. The villages were substituted due to security related issues and due to lack of access.

Results

Over the 480 target sample size, 467 interviews provided valid answers. Response rate was slightly higher in villages targeted by Phase 1 with 99% compared to 95% for those targeted by Phase 2, where the achieved sample sizes were 239 and 228 respectively. Among the 467 households that provided information, only 1 household required a second visit to interview the respondent (see table 1). Table 1: Achieved sample size

Background characteristic (Townships) # households interviewed Proportion* Hpa An Hlaing B Kwakareik Myawaddy

96 64 79 228

20.0 13.3 16.7 50.0

Total 467 100.0 *accounting for sampling design Table 2: Characteristics of the sampled households, by phase of distribution (N=467)

Background characteristic

Respondent is HH head % (n)

Respondent is female %(n)

HH with child under 5% (n)

HH with visitor on survey day % (n)

HH with forest goer on survey day % (n)

Phase 1 Phase 2

45.1 (108) 55.8 (128)

72.4 (173) 72.5 (165)

50.6 (121) 52.6 (121)

48.8 (117) 17.0 (39)

11.7 (28) 27.7 (64)

Total 50.5 (236) 72.5 (338) 51.6 (242) 32.9 (156) 19.7 (92) There were few differences in the sampled households across distribution phase. Households living in villages targeted by Phase 1 were more likely to have at least one temporary visitor compared to those living in Phase 2 villages (49 vs 17%). On the other hand, households in Phase 2 villages were more likely to have anyone who sometimes works in the forest (28 vs 12%), see Table 2. Table 3: Comparison of average household size on the survey day and at the time of the distribution (N=467)



Average household size (mean)

Average number of usual residents (mean)

Average number of temporary visitors (mean)

Average number of forest goers (mean)

Svy day Time of distribution



Svy day

Time of distribution

Phase 1 Phase 2

6.36 * 5.55

5.48 5.42

5.30 5.23

5.27 5.17

1.06 0.32

0.21 0.26

0.27 0.61

0.26 0.61

Total Mean (range)

5.95 (1-22)

5.45 (1-22)

5.26 (1-20)

5.22 (1-20)

0.69 (1-7)

0.23 (1-5)

0.44 (1-10)

0.43 (1-8)

In general, there were more people in the households on the survey day compared to the distribution time and that was more marked in villages targeted by Phase 1. The comparison of average number of usual residents across time shows that the variations were mostly due to temporary visitor movements as opposed to significant change in family composition (see Table 3). This was logical considering the short period of time (9-13 months) between the distribution and the survey. Table 4: Effectiveness of LLIN distribution


HH received at least 1 LLIN N=467

Average quantity of LLIN received if got any

From the SCI CAP campaign % (n)

From any other source % (n)

From the SCI CAP campaign N=454 Mean (range)

From any other source N=159 Mean (range)

Phase 1 Phase 2

96.7 (231) 97.9 (223)

36.2 (86) 31.7 (73)

2.61 1.94

1.90 1.56

Total 97.3 (454) 33.9 (159) 2.27 (1-7) 1.74 (1-5) The SCI CAP campaign distribution reached 97% of households by giving out at least one LLIN to these families. On average, households received 2.27 LLIN from the campaign (see Table 4). On the other hand, 34% of households had acquired at least one LLIN from any other source (i.e. another distribution or the net was bought in a shop or the market) and the average quantity of LLIN obtained from any other source was 1.74. While the campaign reached a similar proportion of households, those living in Phase 1 villages were more likely to acquire a LLIN from any other source (36 vs. 32%) and the quantity of LLIN received or acquired was significantly higher than in Phase 2 villages.


Table 5: LLIN ownership on the survey day based on number of de facto population and number of LLIN Background characteristic

Household coverage (N=467) HH has enough LLIN to protect all forest goers on svy day (N=92)

HH has enough LLIN to protect all (<5) users on svy day (N=242)

Ratio people / LLIN

HH has at least 1 LLN

HH has at least 1 LLN for every 2 people

HH has at least 1 LLN for every 2 residents (excluding visitors)

All de facto population

De facto population excluding visitors

Phase 1 Phase 2

ALL (239) 97.9 (223)

57.0 (136) 29.6 (67) *

75.8 (181) 33.5 (76) *

89.3 (25) 72.1 (46) *

98.4 (119) 90.9 (110)

1.84 2.98

1.73 2.87

Total 98.9 (462) 43.3 (203) * 54.6 (257) * 77.2 (71) 94.6 (229) 2.40 2.30 Overall, 99% of households owned at least one LLIN on the survey day. However, only 43% had enough LLIN to protect all their members as well as excluding temporary visitors, only 55% households had sufficient nets to ensure all usual residents could access LLIN if they wanted to. Ownership was generally higher in Phase 1 villages and that was particularly marked for universal coverage indicators, where these differences were statistically significant (p<0.001 for both indicators). On the other hand, 77% households had enough LLIN to protect people working in the forest and 95% had sufficient LLIN to ensure all children under 5 years could sleep under an LLIN. Again, these proportions were higher among Phase 1 villages but these were not statistically significant at the 5% precision level. Overall, the ratio between the number of people who stayed in the house the previous night and the number of LLIN shows that there were insufficient LLIN as there were on average 2.40 people per LLIN instead of the expected 2.00. This was also true when considering only usual residents, with 2.30 people per LLIN. However, the comparison across phase tells us that the quantity of LLIN available was not equally spread as the ratios were less than 2 people per LLIN in Phase 1 villages while nearly 3 people per LLIN in Phase 2 villages (see table 5).


Figure 3: LLIN universal coverage versus respondent perception of “sufficient” LLIN

The perception of household respondents about owning “sufficient nets” to ensure all members could access LLIN if they wanted to significantly differ from the common target of 1 LLIN for every 2 people. Indeed, the proportion of respondents that perceived they had enough LLIN was higher than the proportion of households owning 1 LLIN for every 2 people with 88% vs. 57% in Phase 1 and 57% vs. 30% in Phase 2 (see figure 3). Among the 454 households that received at least 1 LLIN from the SCI CAP distribution, 97% were satisfied with the net quality (97% in Phase 1 and 96.7% in Phase 2). Five respondents gave a reason for dissatisfaction; one said the mesh size was too big, three said the mesh size was too small and one said the consistency of the netting material was too hard. Table 6: LLIN use at household level among de facto population the previous night


All households (N=460*)

Households with 1 LLIN for every 2 people (N=202)

No one used a LLIN

Some people used a LLIN

All people used a LLIN

No one used a LLIN

Some people used a LLIN

All people used a LLIN

Phase 1 Phase 2

45.9 18.4

21.1 26.8

32.9 54.8

45.9 16.8

16.3 9.5

37.8 73.7

Total 32.2 23.9 43.8 35.9 14.0 50.2 *in 7 households, no one stayed in the house the previous night Among all households, 44% had all members staying in the house the previous night using a LLIN while in 32% of households, nobody used a LLIN. Interestingly, LLIN use was higher in Phase 2 villages with 55% of households having all people using a LLIN compared to 33% in Phase 1 only. Considering households that have sufficient LLIN (i.e. 1 LLIN for every 2 people), the proportion of households where all members used a LLIN was higher (50 vs. 44%) but there


were also more households were no one used a LLIN (36 vs. 32%). The comparison across phases shows that there were more households where all members used a LLIN in Phase 2 villages compared to Phase 1, with 78 vs. 38%1. Figure 4: Households with all de facto population using a LLIN the previous night in relation to background characteristic and LLIN ownership (N=460)

Figure 4 presents the proportion of households where all members used a LLIN, by phase of distribution, LLIN ownership and household size. It shows that LLIN use for all members was higher among households in Phase 2 villages, those who own 1 LLIN for every 2 people, those with any temporary visitors on the survey day and among households of 5 people or less. These proportions across phases were all statistically significant differences (p<0.01).

1 In Phase 1, the percentage of LLINs is the same, probably reflecting that HHs are not interested in using nets rather than lacking nets to use. This is about net culture and clarifies the need to increase BCC efforts to modify people behaviour to make use of existing nets


Figure 4: Reason for going to bed after 7 pm (N=423)

Phase 1 villages Phase 2 villages

Among the 467 sampled household respondents, 91% went to bed after 7 pm the preceding night. This proportion was higher in Phase 2 villages with 96% versus 86% in Phase 1 villages and this was a statistically significant difference (p<0.001). The main reasons for going to bed later than 7 pm were watching TV, usual habit and still chatting; the proportions were similar across phase of distribution.

Table 7: Number of people and nets found in the sampled households (manual calculations2) Individuals

Phase 1 Phase 2 Total

All de facto population the night before the svy 1264 1151 2415 De facto usual residents the night before the svy 1193 1109 2302 De facto temporary visitors 71 42 113 Under 5 population the night before the survey 168 168 336 All people in hh at time of distribution 1310 1238 2548 Usual residents at time of the distribution 1259 1179 2438 % temporary visitors the night before the survey 5.6% 3.6% 4.7% % temporary visitors at the distribution time 3.9% 4.8% 4.3% LLIN use by household members Phase 1 Phase 2 Total

Number of residents using a LLIN the previous night 475 753 1228 Number of visitors using a LLIN the previous night 8 27 35 Number of under 5 using a LLIN the previous night 74 130 204 % all de facto pop using a LLIN the previous night 38.2% 67.8% 52.3% % residents using a LLIN the previous night 39.8% 67.9% 53.3%

2 The proportions were calculated from the numbers of people and nets reported by respondents as opposed to being produced by the statistical software. Consequently it does not account for sampling design


% visitors using a LLIN the previous night 11.3% 64.3% 31.0% % under 5 using a LLIN the previous night 44.0% 77.4% 61.0% Nets


LLIN 743 438 1181 Conventional nets 141 194 335 Treated nets 3 9 12 Other nets 24 105 129 Total nets all categories 911 745 1656 % LLIN among all nets 81.6% 58.7% 71.3% Nets usually used for sleeping


LLIN 547 398 945 Conventional nets 105 140 245 Treated nets 3 9 12 Other nets 19 54 73 Total nets all categories 674 601 1275 Resulting number of nets not used for sleeping


LLIN 196 40 236 Conventional nets 36 54 126 Treated nets 0 0 0 Other nets 5 51 56 Total nets all categories 237 145 382 % nets not used for sleeping LLIN Conventional nets Treated nets Other nets Total nets all categories

26.4% 25.5% 0.0% 20.8% 26.0%

9.1% 27.8% 0.0% 48.6% 19.4%

20.0% 26.9% 0.0% 43.4% 23.1%

Table 7 looks at the actual numbers of people and nets, by category, found in the sampled households. It shows that at the time of the survey, there were 5% of people in the households that were temporary visitors and 4% at the time of the distribution. However, the pattern was reversed across phase with more visitors in Phase 1 at the time of the survey but more visitors in Phase 2 at the time of the distribution. Considering reported numbers of people, it shows that 52% of all people used a LLIN the previous night and this proportion was much higher in Phase 2 villages (69 vs. 38%). LLIN use was lower among temporary visitors, with 31% but the gap between LLIN uses among residents was quite narrow in Phase 2 villages (64 vs. 68%) as opposed to 11 vs. 40% in Phase 1 villages). This suggests that in Phase 2 villages, where LLIN use was more common, either visitors travel with their own net or household members share their LLIN with them. Lastly, LLIN use among under 5 was 61% and again was higher in Phase 2 villages with 77 vs. 44%.


Among all nets, 71% were LLIN, with a higher proportion in Phase 1 villages (82 vs. 59%). However, there were a substantial proportion of nets that went unused or were used for another purpose than sleeping; 20% of all LLIN went unused or were repurposed and this was more likely to be the case in Phase 1 villages. An even higher proportion of conventional nets went unused or were repurposed, with 27% and this proportion was similar across phase.

Discussion

a. Was the campaign effective to achieve Universal Coverage?

The campaign was effective in reaching households as the vast majority received one LLIN or more. Resulting from this, household ownership of at least one net one year after the distribution was high, and LLIN were available to protect most of the vulnerable population such as children under 5 and people working in the forest. However, the quantity of LLIN available in households was too low to effectively ensure access to LLIN to the target of 80% of the population. While this was particularly true for Phase 2 villages, it appeared that LLIN were unevenly spread in phase 1 with some households having too many nets and other not having enough.

On one hand, the campaign significantly raised LLIN ownership in the target area. Prior to the distribution, a mini census was conducted in late 2012 and during this exercise, LLIN ownership and use was estimated among a representative sample of households in the same four Townships. LLIN was found to be very low with 11% of households with at least 1 LLIN, 1% of households with 1 LLIN for every 2 people and 9% of household nets that were LLIN. This suggests that the SCI CAP-Malaria campaign significantly raised the household coverage from the pre distribution coverage. While confounding factors cannot be entirely excluded, it is reasonable to attribute most of the change to that particular campaign.

On the other hand, the quantity of LLIN available for the distribution seems appropriate to cover the needs. Considering that these data were collected between 9 to 12 months after the distribution, it is reasonable to assume that a certain proportion of LLIN that were distributed were already discarded by the households at the time of this assessment. Indeed, the decrease of household coverage achieved by a campaign, if there is no mechanism in place to replace deteriorated LLIN on a continuous basis is well documented in the literature. Soon after a distribution, some nets get lost, disposed or too damaged to be used for sleeping. This phenomenon was modelled3 to simulate the decay function of LLIN. Assuming 1-year LLIN durability in the target area, 8% of nets would be expected to be discarded or lost.

Therefore, it seems reasonable to conclude that the campaign was very effective in reaching households. The quantity of LLIN distributed during the campaign appeared to be sufficient, in theory, to ensure universal access to all people in the sampled households. However, it seems that LLIN allocation according to the demand was more of a challenge and resulted in some oversupply, particularly in Phase 1 and some under supply, more common in Phase 2.

a. Are LLIN widely used in the target villages?

The use of LLIN in the night prior to the survey was quite different across distribution phases. In Phase 1 villages, 38% people used a LLIN, which in some modeling is far too low to effectively impact on malaria transmission. However, some modeling indicates that LLIN user rates as low as 35% can have a good effect on reducing transmission. In Phase 2

3 Albert Kilian and Nakul Chitnis


villages, LLIN use was 68%, which comes nearer to the 80% RBM target. LLIN use was higher among households owning enough nets to ensure universal access. However, similar patterns across phases were observed with 38% of households with all members using a LLIN in Phase 1 compared to 83% in Phase 2. This clearly shows that beyond availability of LLIN, some behavioural aspects may be contributing to the lower than expected LLIN use. Indeed, one fifth of all LLIN (20%) were used for another purpose than sleeping or kept stored away and this was particularly common in Phase 1 were more than a quarter of all LLIN (27%) were not used for malaria prevention. Further work to ascertain the reasons for these practices and the potential role of targeted BCC messages addressing these areas are therefore needed.

Although net use was lower than targets, it was positive to find that Phase 2 villages seemed to have adopted a “net culture” with LLIN widely used providing it is available. A higher perception of risk could have contributed to the differences between phases as in Myawaddy (Phase 2) 60% of positive malaria cases were detected while the other three of Phase 1 townships had 40% of the cases. Villages in Myawaddy (Phase 2) are situated near the Daw Na mountain range (forest-area). The data indicated that in Myawaddy 28% households had at least one member sometimes working in the forest, compared to 12% in Phase 1 villages. As this profession exposes people to a higher risk of malaria transmission, it is reasonable to think these communities are more concerned about the danger of malaria and its prevention.

While the LLIN use was lower than expected in Phase 1, this was not surprising in regard to the fact that LLIN were only recently introduced in these villages (only 11% of households had any LLIN before the campaign). Although BCC activities were conducted during LLIN distribution in all four townships, the large number of migrants moving to and from Myawaddy (a town along the Thailand border) having access to alternative sources of information could be another factor that contributed towards increasing LLIN use in Phase 2 villages. Lastly, there is a small possibility that the difference observed across phase could be confounded by the 3 months’ time difference in implementation. However, this period seems too short to distort the results to such extent that the difference in net ownership and use would be significant.

Conclusion

The campaign was very effective in reaching households and sufficient nets were given out to ensure universal access to all people in the targeted townships. However, households in Phase 1 tended to be oversupplied with LLINs while households in Phase 2 villages were more likely to be undersupplied at the time of the survey. While LLIN use the night before the survey fell short of the 80% RBM target, a “net culture” was successfully introduced and that was particularly true for Phase 2 villages.

Recommendations

a) Pilot a continuous distribution system so households can acquire new LLIN, when necessary, based on their own needs

In order to maintain the gains from this campaign, households must be provided with the possibility to replace their nets when too damaged or torn or when the size of the family increases. A “pull system”, where household make their own decision about their needs for LLIN seems appropriate in this context where nets become a common household product. Therefore, the availability of LLIN in the commercial sector at an affordable price (partially or fully subsidized) could be an appropriate option for all target townships.

b) Strengthen the behaviour change communication component


Awareness of malaria risk and methods for prevention must be maintained. This is particularly important in an environment where disease episodes become a rare occurrence as transmission decreases. Beyond the access to LLIN in the communities, households should be empowered to assess their own needs for malaria prevention and able to decide when they need to acquire a new net in order to protect the whole family. Also, as the programme aims for universal coverage, BCC messaging should stress the importance of community protection effect.

c) Strengthen the M&E plan to generate robust evidence for decision making

If LLIN universal coverage is to remain a key element of malaria prevention in Myanmar, more detailed evaluations will be required to gather robust evidence to guide the strategy. Population access to LLIN is now a standard indicator for universal coverage and requires the collection of information about each individual and each net in the households. These components should be added to future assessments. It will also be essential to collect data on net durability using standard methods. This element is determinant to the strategy to maintain household coverage and generating context specific scientific evidence on net durability, which is a donor requirement in some cases. Further understanding of sleeping habits and time spent under a LLIN is required to better determine the need for alternative personal protection methods to address outdoor malaria transmission.


References

[1] WHO and Global Malaria Programme; 2013, “WHO recommendations for achieving universal coverage with long-lasting insecticidal nets in malaria control.”

[2] Malaria Consortium (internal report); 2012. Rapid Coverage Assessment of Long-lasting Insecticide Nets in Cambodia

[3] Kilian A et al: Universal coverage with insecticide-treated nets-applying the revised indicators for ownership and use to the Nigeria 2010 malaria indicator survey data. Malaria Journal 2013, 12:314

[4] Department of Medical Research (Lower Myanmar), Malaria Consortium, WHO; 2012. Myanmar Artemisinin Resistance Containment Project, Baseline survey.


Annex

rapid coverage assessment of long-lasting … · 23.12.2014 · • dr. thaung hlaing, deputy...

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