Net Values: Meaning, Motivation and Measurement in the Distribution, Use and Monitoring of Bed Nets for Malaria Control in Segou, Mali Public
Patterson, Amy E. (2012)
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
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