Assessing the Feasibility of Continuous Net Distribution in Kenya using Community Based Approach

Background

• Malaria control strategies are based on four principlesEarly diagnosis and treatmentUse of effective medicines Sustainable preventive measures such as vector

control- use of long-lasting insecticidal nets (LLINs)/IRS

Detection, containment and prevention of epidemics

Approaches to increasing net coverage

• Use of LLINs have potential of saving half a million child deaths each year

• Sustained coverage and use of LLINs remains low

• Efforts to increase coverage include: o Social marketingo Catch-up -provision of free nets through clinics/

vaccination campaignso Keep-up-combined strategy through provision of nets

routinely to pregnant-women and children through public health clinics or commercial outlets/vouchers

Why a community approach?

• Shift from vulnerable populations to universal coverage

• Universal coverage- ratio of at least one LLIN for every two household members

• Sustaining universal coverage require innovative ways

• Continuous distribution systems are crucial to maintaining universal coverage

• Operational studies indicate the potential of using a community based model of sustaining universal coverage

Null Hypothesis

• Community based distribution of nets have no effect in sustaining universal coverage

General Objective

• To test the feasibility of sustaining universal coverage achieved during the mass net distribution through community based distribution

Specific Objectives

• To estimate the current number of nets per household in settings where mass distribution was implemented in 2011

• To identify the number of nets in the household that need replacement

• To pilot and document the feasibility of using community based LLIN distribution schemes in maintaining universal coverage

• To assess whether community based redistribution schemes achieve higher utilization rates

Proposed intervention components

Component 1: Establishment of HH registers• CHWs under the supervision of CHEWS will

develop a baseline village register containing HH details

Component 2: Training of CHW/CHEW • Identification of CHWs & CHEWS• Training and sensitization on continuous LLINs

distribution, their expected roles and responsibilities

Proposed intervention components

Component three: Need determination • LLIN need determination at Household level• HHH approaches CHW for verification • CHW gives a coupon to HHH to redeem a net

from facility

Component four: Advocacy and IEC strategies • PHTs to conduct community awareness

programs and integrate messages into health talks

• Use of active district ITN advocacy/ information, education and communication (IEC) groups

Schematic structure of net replacement process

Evaluation approach

Type of evaluation /inference

Performance Impact /OutcomeProvision Utilisation Coverage

Adequacy

(changes occur)

Are net available?

Are nets being used?

Is target population being reached?

Were there improvements in patterns of use?

Plausibility

(effect above and beyond external influence)

Does intervention area appear to perform better?

Are there changes in behaviour that appear to be beneficial to intervention compared to control group?

Probability

(programme effect)

Is intervention better than control group? Are changes in behaviour more beneficial to intervention than control group?

What do you want to measure?

Study design

•Quasi experimental utilizing a plausibility assessment of a before and after study with a control. •Mixed methods-

• Quantitative- to assess the number of nets within the HH/ replacement, utilization of nets

•Qualitative -to assess the feasibility of using community based approaches to distribute the nets

Project sites

• Project site : selected community units in Samia District of Busia County

• Selection criteria : – Communities with a functional community health unit– similar malaria epidemiological profile,– Geographical buffer of about 20 km apart; – Has had mass net distribution taking place, – Malaria endemic with a prevalence of above 38%.

• The district will be divided into intervention and control sites.

Sample size determination

•Expected effect: 10-20%,•Cluster design approach-using a design effect of 2•95% confidence interval and 80% power, •Estimated universal coverage 59.6% in western Kenya (Post Mass Net Evaluation report)•Estimated sample size will be 876 per arm giving an estimated sample size of 1752 HHs in the two study sites

Summary of study activities

Methods Target/No. involved

sampling method

Household survey

House hold heads-1752

Each household in EA selected

Qualitative survey In depth interviews

MoH=4 Convenient sampling methodFacility staff =3

Project implementation=2

Focus group discussions

Community members-6

Data analysis

•Quantitative data from the HHs survey will be collected using android enabled phones/PDAs and submitted to a central server each day.• Data verification, cleaning and analysis will be conducted using STATA version 11 •Using USAID- Tool kit to track community –NetCalc version 2 to estimate coverage•Qualitative data will be stored and managed using Nvivo10

Time line

Activities Months

1 2 3 4 5 6 7 8

Proposal writing and review by the ethics committee

X X

Tool review and inputs X

Field work X X

Analysis of data X

Final write up X

Dissemination activities X