Net Values: Meaning, Motivation and Measurement in the Distribution, Use and Monitoring of Bed Nets for Malaria Control in Segou, Mali Open Access

Abstract

Long-lasting insecticidal bed nets (LLINs) are a key tool for malaria control and elimination. Extensive resources have recently been devoted to scaling-up net coverage in Sub-Saharan Africa. To maximize the benefits of nets in the context of global elimination and eradication efforts, there is a need for better strategies for distributing and monitoring LLINs, and encouraging universal net use.

The primary objectives of this study were to describe practices of LLIN distribution, use and monitoring in a region with an existing net culture; to identify advantages and disadvantages of integrating LLIN delivery and monitoring with immunization services; to characterize factors that motivate or inhibit LLIN use among adults; and to understand the effects of social, linguistic and health systems factors on health worker performance and end-user uptake of malaria interventions.

Data were collected in Segou, Mali, from August 2008 to December 2009, in the context of a larger quasi-experimental evaluation of The Expanded Program for Immunizations (EPI) Contact Method, using a multi-phased mixed methods design. Qualitative methods included unstructured observations, participant observation, semi-structured interviews with health workers (N=89), semi-structured interviews (N=82) and focus groups (N=26) with parents of young children, and key informant interviews (N=16). Sources of quantitative data included systematic observations at EPI clinics (N=1,394), health facility records, and a household survey (N=3,283).

The findings are presented in three chapters, devoted separately to 1) routine integrated LLIN distribution, 2) potential determinants of universal LLIN use where ownership and use among children are already high and 3) health worker performance of the EPI Contact Method as a malaria monitoring and program management tool.

Together, the results highlight the influence of complex relationships between socio-cultural and health systems factors on the delivery, uptake and monitoring of malaria interventions, and draw attention to possible intended and unintended effects of current policies, performance targets and practices on the malaria control and EPI programs in Mali, while also illustrating challenges for
measuring net ownership and use. Recommendations are made for preparing for the transition to a universal LLIN coverage strategy in Mali, for strengthening integrated approaches to LLIN distribution, and for improving measurement.

Table of Contents

CHAPTER 1: Introduction and Literature Review 1
Challenges For The Global Eradication Agenda 3
Insecticide-treated Nets for Malaria Control and Elimination 15
Research Context: The Malaria Situation in Mali, West Africa 33
The Study Site: Segou, Mali 38
Study Overview 39
References 40
Chapter 1 Notes 59

CHAPTER 2: Overview of the Mixed Methods Research Design 60
Mixed Methods Research Designs 60
Overview of the Research Design: A Four-Phase Mixed Methods Study 62
Triangulation: A Strategy to Strengthen the Validity of Conclusions 65
Data Collection Methods 62
References 75

CHAPTER 3: Intended and Unintended Synergies and Cascade Effects: Applying a Systems Thinking Approach to Integrated LLIN Distribution and Expanded Program for Immunization Services in Segou, Mali 76
Abstract 76
Background and Introduction 78
Methods 83
Results 93
Discussion 116
Conclusions 123
References 124
Chapter 3 Notes 128


CHAPTER 4: Preparing for the Transition to Universal LLIN Coverage: Factors that Motivate, Inhibit and Interrupt LLIN Use among Persons of all Ages in Segou, Mali129
Abstract 129
Background and Introduction 131
Methods 136
Results 144
Discussion 159
Conclusions 171
References 173
Chapter 4 Notes 180

CHAPTER 5: Health Worker Performance of a Proposed Low-Cost Health Facility-Based Malaria Monitoring and Program Management Tool: Results from a Process Evaluation of the EPI-Contact Method in Segou, Mali 182
Abstract 182
Background and Introduction 184
Methods 189
Results 204
Discussion 217
Conclusions 221
References 231
Chapter 5 Notes 233

CHAPTER 6: Summary and Conclusions 235 Summary of Results and Recommendations 235
Strengths and Limitations of the Study Design and Methods 242
Conclusions 247
References 248
Chapter 6 Notes 250

ANNEXES 251
Annex 1: Acronyms 251
Annex 2: EPI-CM Data Collection and Reporting Forms 253

LIST OF FIGURES
Figure 2.1 Mixed Methods Design1: Data Collection 71
Figure 2.2 Mixed Methods Design 2: Analysis and "Mixing" 72
Figure 4.1 Proposed Conceptual Model of Determinants of LLIN Use 173
Figure 5.1 Multi-level Conceptual Model of the Effects of the EPI-CM 222
Figure 5.2 Variability in the Percentage of Vaccination Clinics during which EPI-CM Data were Collected 224
Figure 5.3 Percent Agreement between Monthly Totals for EPI-CM Indicators in Reports and Tallies (for the subset of monthly report values for which corresponding tally data could be located) 226
Figure 5.4 Differences between Monthly District Totals for the Number of Children who Slept Under a Net the Previous Night Reported in Monthly Reports and Calculated from EPI-CM Tally Notebook Data 227
Figure 5.5 Differences between Monthly District Totals for EPI-CM Child Illness Indicators Reported in Monthly Reports and those Calculated from EPI-CM Tally Notebook Data 228
Figure 5.6 Missing Values for Negative Responses in EPI-CM Tally Data 229
Figure 5.7 Failures to Differentiate between Missing Values and Zero Values in EPI-CM Tally Data 230


LIST OF TABLES
Table 2.1 Research Topics and Associated Research Questions 68
Table 2.2 Relationships between Research Methods and Research Topics 70
Table 2.3 Seasonal Distribution of Days of Systematic Observations of EPI Clinics and Fever Consultations 73
Table 2.4 Seasonal Distribution of Qualitative Interviews with Parents and Health Workers, by Gender and Category 74
Table 4.1 Comparison of Net Ownership, Condition and Use Variables in Segou and Baraoueli Districts 172
Table 5.1 Methods Overview 223
Table 5.2 Differences in the Information Communicated during Observed Vaccination Clinic Client-Provider Interactions in Segou (Intervention) and Baraoueli (Comparison) Districts 225

About this Dissertation

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School	Laney Graduate School
Department	Behavioral Sciences and Health Education
Degree	PhD
Submission	Dissertation
Language	English
Research Field	Health Sciences, Public Health
Keyword	Insecticidal Nets Monitoring and Evaluation Malaria Health Systems Integration Mali
Committee Chair / Thesis Advisor	Sterk, Claire E, Emory University
Committee Members	McFarland, Deborah A, Emory University McMorrow, Meredith L., Centers for Disease Control and Prevention Brown, Peter J, Emory University

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