Progress in coverage of bed net ownership and use in Burkina Faso : evidence from population based surveys

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1 DOI /s Mlri Journl RESEARCH Open Access Progress in coverge of bed net ownership nd use in Burkin Fso : evidence from popultion bsed surveys Sekou Smdoulougou 1*, Morgn Percy 2, Yzoumé Yé 3 nd Fti Kirkoy Smdoulougou 4,5 Abstrct : Use of insecticide-treted bed nets (ITNs) is the cornerstone of mlri prevention. In 2010 nd 2013, the Burkin Fso Government lunched mss distribution cmpigns of ITNs to increse coverge of ownership nd use in the country. This study ssessed the progress towrds universl bed net coverge in Burkin Fso. Methods: The uthors used dt from the Burkin Fso 2003 nd 2010 Demogrphic nd Helth Surveys (DHS), the 2006 Multiple Indictor Cluster Surveys (MICS) nd the 2014 Mlri Indictor Survey (MIS). For ech survey, the uthors computed key mlri prevention indictors in line with recommendtions from the Survey nd Indictor Tsk Force of the Roll Bck Mlri Monitoring nd Evlution Reference Group. The trends over decde ws ssessed by clculting percentge point chnge between 2003 nd Results: At ntionl level, the proportion of households owning t lest one ITN incresed substntilly from 5.6, 95% CI (4.7, 6.5%) in 2003 to 89.9% (88.5, 91.2%) in 2014, with low heterogeneity between regions. The proportion of households owning t lest one ITN per two people incresed significntly from 1.8% (1.4, 2.3%) in 2003 to 49.2% (47.3, 51.0%) in ITN use in the generl popultion incresed from 2.0% (1.6, 2.3%) in 2003, to 67.0% (65.3, 68.7%) in A similr trend ws observed mong children under the ge of five yers, incresing from 1.9% (1.5, 2.4%) in 2003 to 75.2% (73.2, 77.3%) in 2014, nd mong pregnnt women, incresing from 3.0% (1.9, 4.2%) in 2003 to 77.1% (72.9, 81.3%) in The intr-household ownership gp ws 67.0% (61.5, 72.4%) in 2003, but decresed significntly to 45.3% (43.6, 47.1%) in The behviourl gp, which ws reltively low in 2013 with only 20.0% of people who hd ccess to n ITN but were not using it, further decresed to 5.9% in Conclusion: Burkin Fso mde considerble progress in coverge of ITN ownership, ccess nd use between 2003 nd 2014, s result of the two free mss distribution cmpigns in 2010 nd However, ITN coverge remins below the ntionl trgets of 100% for ownership nd 80% for use. The results of 90% of ownership nd 67% of use confirm tht free mss distribution cmpigns of ITNs re effective; however, there is room for improvement to rech nd mintin optiml coverge of ITN ownership nd use. Keywords: Bed net, LLIN ownership gp, LLIN use gp, LLIN ccess gp, Behviourl filure, Mlri Insecticide-treted bed nets (ITNs) re effective tools for mlri control [1]. Met-nlyses hve shown tht ITNs *Correspondence: sekou.smdoulougou@uclouvin.be 1 Pôle Epidémiologie et Biosttistique, Institut de Recherche Expérimentle et Clinique (IREC), Fculté de Snté Publique (FSP), Université ctholique de Louvin (UCL), Clos Chpelle ux chmps 30, bte B , 1200 Bruxelles, Belgium Full list of uthor informtion is vilble t the end of the rticle re ssocited with n 18% reduction in child mortlity [2], 51% decrese in uncomplicted mlri incidence nd 17% reduction in prsite prevlence in children [3]. In the pst decde, the rpid scle-up of bed nets in sub-shrn Afric (SSA) contributed to the significnt decline of mlri burden in the region [4, 5]. Sustining high coverge of this intervention is criticl to decrese further the burden of the disese nd rech the long term-gol of mlri elimintion. It is estimted tht The Author(s) This rticle is distributed under the terms of the Cretive Commons Attribution 4.0 Interntionl License ( which permits unrestricted use, distribution, nd reproduction in ny medium, provided you give pproprite credit to the originl uthor(s) nd the source, provide link to the Cretive Commons license, nd indicte if chnges were mde. The Cretive Commons Public Domin Dediction wiver ( publicdomin/zero/1.0/) pplies to the dt mde vilble in this rticle, unless otherwise stted.

2 Pge 2 of 12 minimum of 150 million ITNs per yer re needed to mintin constnt pool of 450 million functioning ITNs to protect individuls t risk in SSA [6]. Incresing ITN coverge hs been chieved using vrious distribution strtegies, including socil mrketing [7 9], free distribution to trget vulnerble groups (pregnnt women nd children under the ge of five) through ntentl cre (ANC) or immuniztion cmpigns [7, 8, 10 12], nd more recently, free, universl, popultion-bsed distribution cmpigns trgeting the generl popultion [7, 8, 10, 12 18]. The World Helth Orgniztion (WHO) recommends to distribute free or subsidize bed nets s the best wy to ensure full coverge [19]. In 2001, ntionwide survey in Burkin Fso estimted tht only 12.4% of children under the ge of five were sleeping under net, compred to 23.2% in Among pregnnt women this proportion ws 10.0% in 2001 nd 27.5% in 2005 [20]. To rpidly increse coverge of ITN ownership nd use, prticulrly mong vulnerble groups, the Government of Burkin Fso initited first ntionl-scle, free distribution cmpign of ITNs in The im of the cmpign ws to ensure tht households hd ccess to t lest one ITN for every two people through the distribution of bout eight million long-lsting insecticidl nets (LLINs). Moreover, in 2013, the ntionl mlri control progrmme (NMCP) lunched the second free LLIN distribution cmpign to scle-up the coverge of ITNs in the country. This cmpign imed to ensure tht 100% of households owned t lest one ITN, nd rech 80% ITN use by In 2014, the Burkin Fso Government decided to conduct the first Mlri Indictor Surveys (MISs) to ssess coverge nd impct of scled-up mlri interventions. MISs were developed by the Roll Bck Mlri (RBM) Monitoring nd Evlution Reference Group (MERG) with the im to help ntionl ministries of helth collect key nd timely informtion on mlri control t ntionl level [21]. As Burkin Fso ims to chieve universl coverge with LLINs, this pper ssessed the progress nd gps in coverge of bed net ownership nd use bsed on RBM/ MERG-recommended indictors [21]. Methods The uthors nlysed regionl trends of ITNs ownership, ccess nd use indictors in Burkin Fso over 11 yers. These indictors were computed using dt from the 2003 nd 2010 Demogrphic nd Helth Surveys (DHS) [22, 23], 2006 Multiple Indictors Cluster Survey (MICS) [24] nd the first ntionl MIS 2014 [25]. At the time of these surveys, Burkin Fso ws divided into 13 dministrtive regions. Dt from Demogrphic nd Helth Survey 2003 nd 2010 DHS 2003 (between June nd December 2003) nd DHS 2010 (between My 2010 nd Jnury 2011) were conducted during the high trnsmission seson. DHS ws designed to obtin ntionl nd regionl estimtes for mlri indictors. The DHS surveys followed twostge selection process in which rndom smple of clusters ws first selected from the most recent ntionl smple frme. In the second stge, ll households were listed nd the finl list of households selected by systemtic rndom smple. In the Burkin Fso DHS, the smple ws selected in two stges, strtified by plce of residence (urbn nd rurl) with enumertion res (EAs) s the first-stge smpling units, nd households s the secondstge smpling units. Further detils re provided in the DHS reports [22, 23]. Dt from MIS 2014 The MIS dt were collected from October to November 2014 (t the end of the high trnsmission seson), using the stndrd mlri indictor questionnires developed by the RBM nd the DHS Progrm. The dtset consists of mlriometric informtion, demogrphic s nd socio-economic sttus on ntionlly representtive smple of 6448 households from 252 clusters, of which 52 re in the urbn res. These clusters were derived from strtified two-stge cluster design. A detiled description of the smpling strtegies is documented in the finl report of the 2014 Burkin Fso MIS [25]. Dt from MICS 2006 Multiple Indictor Cluster Surveys re typiclly crried out by government orgniztions with the support nd ssistnce of UNICEF to fill dt gps for monitoring the children nd women wellbeing. The Burkin Fso MICS conducted from Mrch to June 2006 used two-stge strtified smple design. At the first stge of smpling, 198 census EAs (197 visited) were selected. The clusters in ech region were selected using systemtic smpling with probbility proportionl to their size. A complete household-listing exercise covering ll EAs in the 2003 Burkin Fso DHS ws crried out. At the second stge, systemtic smpling of households ws selected bsed on this list. For the 2006 Burkin Fso MICS, 30 households per EA were selected per rurl EA, 32 (in Ougdougou, the cpitl city) to 36 households per urbn EA. Due to the fixed smple size per EA, the disproportionl number of EAs nd different smple sizes selected per EA mong regions, the household smple is not self-weighting t the ntionl level. A more detiled description of the smple design cn be found elsewhere [24].

3 Pge 3 of 12 Indictors Ownership, ccess, use, nd gp indictors were clculted from the dtsets of households nd individul household members, s recommended by MERG [21] (Tble 1). Sttisticl methods Dt ws nlysed using Stt version 14 softwre nd the mps were mde using the R softwre. Point estimtes (in percentge) nd 95% confidence intervls were computed for ech indictor nd dt point. In ddition the percentge point chnges between the bseline (2003) nd endline (2014) were computed to ssess chnge in the indictor nd sttisticl significnce ssess t 5% level. Chnge by region nd socio-demogrphicl fctor of ech indictor between 2003 nd 2014 were explored using the difference between weighted proportions (with svy prop commnd for survey dt nlysis) in Stt version 14 followed by Lincom commnd (Liner combintion of estimtors). The survey men commnd followed by Lincom (to compute two-smple t-test for difference in mens with smpling weights) ws used for the continuous vrible ccess. Using this pproch, we were directly testing whether the observed difference ws significntly superior to zero. Results ITN ownership t household level (referred to s percentge 1 P1) Respectively, 9097, 6034, 14,424, nd 6448 households were visited in the DHS 2003, MICS 2006, DHS 2010, nd MIS Ownership of ITN t household level in Burkin Fso ws 5.6, 95% CI (4.7, 6.5%) in 2003, 23.3% (19.8, 27.3%) in 2006, 56.9% (54.8, 59.0%) in 2010, compred to 89.9% (88.5, 91.2%) in 2014 (Fig. 1). Overll ownership of ITNs t household level incresed significntly from 2003 to 2014 (p < 0.001, Fig. 1). Ownership of ITNs in rurl res incresed from 3.2% in 2003 to 90.8% in 2014 (p < 0.001). In urbn res, percentge point increse of 72.5 of ITN ownership by households ws observed from 2003 to 2014 (p < 0.001). In 2003, the richest households hd the highest level of ITN ownership (15.8 vs 1.8% for poorest households). In 2014, ITN ownership incresed nd reched 84.4% in the poorest quintile compred to 87.4% in the richest quintile (Tble 2). Insecticide-treted bed nets coverge lso incresed significntly in different regions from 2003 to The percentge point increses were consistently high cross regions (from 76.9 to 94.5). Compred to 2003 nd 2010, ITN ownership ws rther stble cross the country nd displyed limited geogrphic heterogeneity in 2014 (Fig. 2). ITN ownership t household level (P2: households with t lest one ITN for every two people) The proportion of households with enough ITNs for every household member, i.e., t lest one ITN for every two people, ws 1.8% (1.4, 2.3%) in 2003, 8.4% (6.1, 11.4%) in 2006, 18.5% (17.1, 20.0%) in 2010, compred to 49.2% (47.3, 51.0%) in 2014, indicting substntil increse (p < 0.001). Household ccess to ITNs improved significntly from 2003 to 2014 in urbn nd rurl res, in ll quintiles of welth nd in the different regions in Burkin Fso. The lrgest increses were observed in urbn res mongst the richest two quintiles, in smllest households nd in the Huts-Bssins nd Centrl-South regions (Tble 3). In these two regions, 62.5 nd 60.4% households, respectively, owned t lest one ITN for every two members in 2014 (Fig. 2). Access to ITN t popultion level (P3) Access to ITNs incresed significntly from 2.5% (2.1, 3.0%) in 2003, to 13.4% (11.0, 15.9%) in 2006, 36.1% (34.1, 38.0%) in 2010, nd reched 71.2% (69.6, 72.8%) in 2014 (p < 0.001) (Tble 4; Fig. 1). Use of ITN t individul level (P4) In 2003, 2.0% (1.6, 2.3%) slept under net. In 2010, the proportion of people who slept under n ITN ws 31.5% (29.8, 33.2%) compred to 67.0% (65.3, 68.7%) in 2014, suggesting considerble increse of 65.0% points from 2003 to 2014 (p < 0.001, Fig. 1). In urbn res, 5.6% of individuls used ITNs in 2003, proportion tht incresed to 61.8% by 2014 (p < 0.001). In rurl res, significnt increse ws lso observed, with 1.2% of people who used n ITN in 2003 nd 68.8% in 2014 (p < 0.001). The substntil increse in the proportion of people who slept under ITNs ws observed cross ll quintiles of welth. Use of ITNs incresed significntly from 0.8% in 2003 to 63.7% in 2014 (p < 0.001) in the poorest welth quintile. In the second poorest welth quintile, ITN use incresed from 0.8% in 2003 to 69.1% in 2014 (p < 0.001), compred to n increse of 54.9% points in the richest quintile ( %) (Tble 5). In terms of regions, the lrgest increse occurred in the Centrl-Est nd Centrl-South regions. The bsolute increse in ITN use in the Centrl-Est region ws 75.9% points (p < 0.001), incresing from 2.6% in 2003 to 78.6% in The corresponding estimtes for the Centrl-South region were 1.4% in 2003 nd 75.4% in 2014 (p < 0.001) (Fig. 3). Use of ITN mong children under 5 yers of ge (P5) In 2003, 1.9% (1.5, 2.4%) of children under 5 yers of ge were sleeping under n ITN, compred to 9.6% (7.6,

4 Pge 4 of 12 Tble 1 RBM/MERG-pproved indictors used Indictor Numertor Denomintor Ownership Proportion of households in the survey with t lest one ITN (P1) Proportion of households with sufficient ccess to ITN (P2) Proportion of popultion with ccess to ITN within the household (P3) Proportion of households with t lest one ITN for every two people mong households owning ny ITN (P7) Number of households owning t lest one ITN Number of households owning t lest one ITN for every two household members Potentil number of household members protected by the ITN (i.e., number of ITN owned multiplied by two), or number of de fcto household members in the household, whichever ws the lowest Number of households owning t lest one ITN for every two household members Number of households in the survey Number of households in the survey Popultion in the survey Number of households owning t lest one ITN Intr-ownership gp, the proportion of households owning less thn one ITN for every two household members, is clculted s 1-P7 Use Proportion of popultion sleeping under n ITN the previous night (P4) Number of household members who slept under n ITN the night before the survey Popultion in the survey Proportion of children under 5 yers sleeping under n ITN the previous night (P5) Proportion of pregnnt women sleeping under n ITN the previous night (P6) Proportion of popultion sleeping under n ITN the previous night mong those with ccess (P8) Number of children under 5 yers who slept under n ITN the night before the survey Number of pregnnt women who slept under n ITN the night before the survey Number of household members who slept under n ITN the night before the survey Number of children under five yers in surveyed households Number of pregnnt women in surveyed households Totl number of people with ccess to n ITN, clculted s the sum of ll ccess (P3) vlues Behviourl gp, the proportion of household members who did not sleep under n ITN despite hving ccess to one, is clculted s 1-P8 11.6%) in 2006, 47.4% (45.3, 49.5%) in 2010, nd 75.2% (73.2, 77.3%) in 2014 (Tble 5). Overll, the use of ITNs mong children under five yers hs incresed significntly from 2003 to 2014 (p < 0.001) (Fig. 1). Anlysis of ITN use by ge bnd showed significnt increse from 2003 to In children younger thn 12 months, use of ITNs incresed from 1.9% in 2003 to 77.0% in 2014 (p < 0.001). Among children ged months, the proportion tht used ITNs incresed from 2.2% in 2003 to 76.7% in 2014, suggesting n bsolute increse of 74.5% points between the two periods (p < 0.001). Substntil increses in the use of ITNs lso were observed in older children (ges 24, 36 nd 48 months) from 2003 to 2014 (Tble 6). In urbn settings, 6.2% of children under five yers slept under n ITN in 2003, compred to 69.9% in 2014, indicting n bsolute increse of 63.7% points (p < 0.001). In 2003, 1.3% of children under 5 yers living in rurl res slept under n ITN. This proportion incresed significntly in 2014, reching 76.8% in children under 5 yers living in rurl res (p < 0.001). In welth quintiles, the smllest increses were observed in children under 5 yers from the richest welth quintile, with n increse from 7.0% in 2003 to 69.7% in 2014 (Tble 6). Mrked increses in ITN use were lso chieved in ll regions over the specified period; however, the Centre- Est nd Centre-Nord regions displyed the gretest increse in ITN use compred to the other regions with n increse from 2.5 to 86.5% nd from 0.5 to 82.1% (Tble 6, Fig. 3). Use of ITN mong pregnnt women (P6) The use of ITNs by pregnnt women in Burkin Fso ws 3.0% (1.9, 4.2%) in 2003, 44.5% (41.2, 49.%) in 2010, nd 77.1% (72.9%, 81.3%) in 2014, indicting significnt increse from 2003 to 2014 (p < 0.001) (Fig. 1). In urbn res, 7.5 nd 69.6% of pregnnt women used ITNs in 2003 nd 2014, respectively, n increse of 62.1% points (p < 0.001, Tble 7). The corresponding estimtes in rurl res were 2.1% in 2003 nd 78.8% in 2014, significnt improvement in ITN use mong pregnnt women between these periods (p < 0.001). A trend similr to tht of ITN use in children under five yers ws found when nlyses were performed by welth quintile. ITN ownership nd use gps In 2003, 94.4% (93.5, 95.2%) of the study households did not possess n ITN (Fig. 1). Among those who owned t lest one ITN, 67.0% (61.5, 72.4%) did not hve sufficient

5 Pge 5 of Own t lest 1 ITN 1 ITN per 2 members Acces to ITN b c Whole popultion Children under 5 Pregnnt Women DHS 2003 MICS 2006 DHS 2010 MIS Ownership Gp Behviourl Gp Fig. 1 Trends of min mlri prevention indictors between 2003 nd 2014, Burkin Fso. Pnel A (ITN ownership) represents the proportion of households owning t lest 1 ITN, owning 1 ITN for 2 household members nd the proportion of individuls with ccess to n IT. Pnel B (ITN use) represents the proportion of people who slept under n ITN the night before the survey for the whole popultion, mong children under five yers old nd mong pregnnt women. Pnel C (gp indictors) represents the proportion of household onwing t lest 1 ITN, but less thn 1 for every 2 household members (intrownership gp), nd the proportion of people hving ccess to n ITN but who did not use it the night before the survey (behviourl gp). All indictors re plotted for the 2003, 2006, 2010 nd 2014 surveys, long with their 95% confidence intervl bed nets to protect ll members (intr-household net ownership gp). However, 19.4% (n = 94) of these households hd excess ITNs (i.e., more thn one ITN for every two people). A significnt proportion (21.9%, n = 316) of the popultion with sufficient ccess to ITNs did not ctully use them the night before the survey. In 2010, 43.0% (41.0, 45.2%) of the study households did not hve n ITN. The intr-household net ownership gp ws 67.6% (65.8, 69.3%), indicting tht bout two-thirds of the households with t lest one ITN did not hve sufficient ITNs to protect ll members. This gp is presented in Tble 8 by bckground s nd shows tht the gp ws very high in lrge household size (93.4%) nd rurl res (70.4%). However, 18.3% (n = 1475) of these households hd excess ITNs (i.e., more thn one ITN for every two people). A smll proportion (12.7%, n = 3700) of the popultion with sufficient ccess to ITNs did not ctully use them. In 2014, only 10.6% (9.2, 12.0%) of the study households did not hve n ITN. The intr-household net ownership gp ws 45.3% (43.6, 47.1%), indicting tht bout hlf of the households with t lest one ITN did not hve sufficient ITNs to protect ll members. This gp ws 80.7% in lrge household size nd well bove the ntionl verge (Tble 8). However, 34.5% (n = 1926) of these households hd excess ITNs (i.e., more thn one ITN for every two people). A smll proportion (5.9%, n = 1562) of the popultion with sufficient ccess to ITNs did not ctully use them. In contrst, this proportion ws 13.1% in urbn res nd only 3.4% in rurl res (Tble 9). Discussion The Government of Burkin Fso set ntionl gol to increse ITN ownership, ccess nd use. These dt provide evidence of the remrkble increse in the coverge of ITN ownership, prticulrly in 2014 fter the second free distribution cmpign. Indeed, ownership, ccess nd use indictors clculted following MERG s recommendtions [21] drmticlly incresed between 2003 nd 2014 nd ws prticulrly successful t reching the poorest popultions. The incresing trend in ITN ownership described here, is consistent with dt from 19 SSA countries during similr time period [26]. The dt show tht the two free distribution cmpigns substntilly incresed ITN ownership nd reduced inequity mong popultions in Burkin Fso. These findings re consistent with other free mss distribution cmpigns tht hve been crried out in SSA [9, 27], demonstrting tht this strtegy cn be used to rpidely scle-up ITN coverge in res with low coverge nd reduce socil inequity. However, despite the significnt progress, less thn 50% of households own enough ITNs to protect every household members (Fig. 1). These cmpigns should not represent the only mechnism by which ITNs re distributed to poorest communities nd vulnerble popultions [9]. In Burkin Fso, ITNs were provided for free to pregnnt women nd children under five yers

6 Pge 6 of 12 Tble 2 Proportion of households owning t lest one insecticide-treted bed net DHS 2003 MICS 2006 DHS 2010 MIS 2014 Percentge point chnge ( ) Urbn 14.8 ( ) ( ) ( ) ( ) ( ) Rurl 3.2 ( ) ( ) ( ) ( ) ( ) Household welth quintiles Poorest 1.8 ( ) ( ) ( ) ( ) ( ) Poorer 2.6 ( ) ( ) ( ) ( ) ( ) Averge 2.8 ( ) ( ) ( ) ( ) ( ) Richer 3.8 ( ) ( ) ( ) ( ) ( ) Richest 15.8 ( ) ( ) ( ) ( ) ( ) Smll (1 5 members) 6.0 ( ) ( ) ( ) ( ) ( ) Medium (6 8 members) 5.5 ( ) ( ) ( ) ( ) ( ) Lger (9+ members) 4.8 ( ) ( ) ( ) ( ) ( ) CI Confidence intervls, DHS Demogrphic nd Helth Survey, MICS Multiple Clusters Indictor Survey, MIS Mlri indictor Survey, N number of households DHS 2003 MICS 2006 DHS 2010 DHS 2014 Legend b c % 80-90% 70-80% 60-70% 50-60% 40-50% 30-40% 20-30% 10-20% 0-10% Fig. 2 Trends of min ownership indictors between 2003 nd 2014, Burkin Fso. The proportion of households owning t lest 1 ITN (), owning t lest 1 ITN for 2 household members (b) nd the proportion of the popultion with ccess to n ITN (c) is indicted for ech region, for 2003, 2006, 2010, nd 2014, respectively of ge through routine chnnels, such s ntentl cre nd immuniztion cmpigns. ITNs were lso vilble for purchse in retil shops nd stores. This could explin both the slight increse in bed net ownership (Fig. 1) nd use (Fig. 3). However, the reltive contribution of these distribution chnnels remins, to dte, very limited. More thn 90% of the ITNs were obtined during the free distribution cmpign [25]. To rech nd mintin high ITN coverge in Burkin Fso, there is need to improve the contribution of the routine distribution through ANC nd vccintion progrms nd develop lterntive strtegies, such s the continuous distribution of ITN in schools nd by community helth workers for replcement [28]). Ownership nd behviourl gp nlyses provide complementry informtion regrding ITN ownership nd use. The results revel geogrphicl nd sociogeogrphic

7 Pge 7 of 12 Tble 3 Proportion of households owning t lest one insecticide-treted bed net for every two members DHS 2003 MICS 2006 DHS 2010 MIS 2014 Percentge point chnge ( ) Urbn 5.8 ( ) ( ) ( ) ( ) ( ) Rurl 0.8 ( ) ( ) ( ) ( ) ( ) Household welth quintile Poorest 0.6 ( ) ( ) ( ) ( ) ( ) Poorer 0.2 ( ) ( ) ( ) ( ) ( ) Averge 0.5 ( ) ( ) ( ) ( ) ( ) Richer 0.8 ( ) ( ) ( ) ( ) ( ) Richest 6.5 ( ) ( ) ( ) ( ) ( ) Smll (1 5 members) 3.3 ( ) ( ) ( ) ( ) ( ) Medium (6 8 members) 0.7 ( ) ( ) ( ) ( ) ( ) Lrge (9+ members) 0.1 ( ) ( ) ( ) ( ) ( ) CI Confidence intervls, DHS Demogrphic nd Helth Survey, MICS Multiple Clusters Indictor Survey, MIS Mlri indictor Survey; N number of households Tble 4 Proportion of popultion hving ccess to n insecticide-treted bed net DHS 2003 MICS 2006 DHS 2010 MIS 2014 Percentge point chnge ( ) Urbn 8.1 ( ) 12, ( ) ) 21, ( ) ( ) Rurl 1.3 ( ) 46, ( ) 32, ( ) 58, ( ) 31, ( ) Household welth quintiles Poorest 0.7 ( ) 10, ( ) ( ) 15, ( ) ( ) Poorer 0.9 ( ) 11, ( ) ( ) 15, ( ) ( ) Averge 1.1 ( ) 14, ( ) ( ) 16, ( ) ( ) Richer 1.5 ( ) 10, ( ) ( ) 16, ( ) ( ) Richest 8.3 ( ) 12, ( ) ( ) 16, ( ) ( ) Smll (1 5 members) 4.2 ( ) 14, ( ) ( ) 27, ( ) 11, ( ) Medium (6 8 members) 2.7 ( ) 16, ( ) 11, ( ) 26, ( ) 12, ( ) Lrge (9+ members) 1.5 ( ) 28, ( ) 19, ( ) 26, ( ) 15, ( ) CI Confidence intervls, DHS Demogrphic nd Helth Survey, MICS Multiple Clusters Indictor Survey, MIS Mlri indictor Survey, N number of individuls discrepncies of ITN ownership nd use. Gp decresed (>10% point chnge) in ll regions, with highest decreses in the Huts-Bssins nd, in the Sud-Ouest hlf of the country (zones where mlri trnsmission is permnent with pek during the riny seson). Shel, Nord nd Centre-Est (where mlri trnsmission is sesonl) disply lower gp reduction, but the ownership gp ws lredy low in Chnge in mlri trnsmission my explin this difference. In 2014, geogrphicl discrepncies in the ownership gp were minimum. Remrkbly, the ownership gp incresed in Centre- Nord. This increse cn be ttributed to the 2003 gp vlue, which is clerly n outlier: 35.8% gp, while the gp in ll other regions fell between 59 nd 90 (Fig. 4). By contrst with ownership gp, behviourl gp remined stble cross the country. However, significnt decrese ws observed in Boucles de Mouhoun, Centre, Centre-Sud, nd Centre-Est. All four regions displyed higher-thn-verge behviourl gp in In this respect, Centre consistently displyed higher behviourl

8 Pge 8 of 12 Tble 5 Proportion of popultion who slept under n insecticide-treted bed net the night before the survey DHS 2003 MICS 2006 DHS 2010 MIS 2014 Percentge point chnge ( ) Urbn 5.6 ( ) 12, ( ) 21, ( ) ( ) Rurl 1.2 ( ) 46, ( ) 58, ( ) 31, ( ) Household welth quintiles Poorest 0.8 ( ) 10, ( ) 15, ( ) ( ) Poorer 0.8 ( ) 11, ( ) 15, ( ) ( ) Averge 0.9 ( ) 14, ( ) 16, ( ) ( ) Richer 1.3 ( ) 10, ( ) 16, ( ) ( ) Richest 6.1 ( ) 12, ( ) 16, ( ) ( ) Smll (1 5 members) 3.1 ( ) 14, ( ) 27, ( ) 11, ( ) Medium (6 8 members) 2.1 ( ) 16, ( ) 26, ( ) 12, ( ) Lrge (9+ members) 1.2 ( ) 28, ( ) 26, ( ) 15, ( ) CI Confidence intervls, DHS Demogrphic nd Helth Survey, MICS Multiple Clusters Indictor Survey, MIS Mlri indictor Survey, N number of individuls Dt not vilble DHS 2003 MICS 2006 DHS 2010 DHS 2014 Legend % 80-90% b c 70-80% 60-70% 50-60% 40-50% 30-40% 20-30% 10-20% 0-10% Fig. 3 Trends of min usge indictors between 2003 nd 2014, Burkin Fso. The proportion of the popultion (), of children under 5 yers (b) nd pregnnt women (c) who slept under n ITN the night before the survey is indicted for ech region, for 2003, 2006, 2010 nd 2014 respectively gp vlues for ll yers studied, most likely becuse the popultion in this region is concentrted in urbn hbitt (Ougdougou). This result could be explined by higher popultion dynmics in the cpitl region. Interestingly lso, the chnge in behviour is very recent in this region (in 2010, behviourl gp ws 40%). In 2014, the behviourl gp ws uniformly low cross the country (0 15%). This reduction is probbly result of the helth promotion progrmmes initited by the Government of Burkin Fso to improve wreness concerning mlri prevention methods [25]. Household size is the min fctor ssocited with ownership gp in this study. Lrge households with t lest one bed net lcked dditionl bed nets to protect ll fmily members (vs 25.5% for smll households). Conversely, households in urbn settings nd from the richest

9 Pge 9 of 12 Tble 6 Proportion of children under 5 yers old who slept under n insecticide-treted bed net the night before the survey DHS 2003 MICS 2006 DHS 2010 MIS 2014 Percentge point chnge ( ) Age group (months) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Gender Mle 1.8 ( ) ( ) ( ) ( ) ( ) Femle 2.1 ( ) ( ) ( ) ( ) ( ) Urbn 6.2 ( ) ( ) ( ) ( ) ( ) Rurl 1.3 ( ) ( ) ( ) 11, ( ) ( ) Household welth quintiles Poorest 1.2 ( ) ( ) ( ) ( ) ( ) Poorer 0.7 ( ) ( ) ( ) ( ) ( ) Averge 0.8 ( ) ( ) ( ) ( ) ( ) Richer 1.6 ( ) ( ) ( ) ( ) ( ) Richest 7.0 ( ) ( ) ( ) ( ) ( ) Smll (1 5 members) 2.9 ( ) ( ) ( ) ( ) ( ) Medium (6 8 members) 2.2 ( ) ( ) ( ) ( ) ( ) Lrge (9+ members) 1.3 ( ) ( ) ( ) ( ) ( ) CI Confidence intervls, DHS Demogrphic nd Helth Survey, MICS Multiple Clusters Indictor Survey, MIS Mlri indictor Survey, N number of children Tble 7 Proportion of pregnnt women who slept under n insecticide-treted bed net the night before the survey DHS 2003 MICS 2006 DHS 2010 MIS 2014 Percentge point chnge ( ) Urbn 7.5 ( ) ( ) ( ) ( ) Rurl 2.3 ( ) ( ) ( ) 31, ( ) Household welth quintiles Poorest 1.1 ( ) ( ) ( ) ( ) Poorer 0.7 ( ) ( ) ( ) ( ) Averge 3.2 ( ) ( ) ( ) ( ) Richer 1.5 ( ) ( ) ( ) ( ) Richest 9.4 ( ) ( ) ( ) ( ) Smll (1 5 members) 4.3 ( ) ( ) ( ) 11, ( ) Medium (6 8 members) 2.0 ( ) ( ) ( ) 12, ( ) Lrge (9+ members) 2.5 ( ) ( ) ( ) 15, ( ) CI Confidence intervls, DHS Demogrphic nd Helth Survey, MICS Multiple Clusters Indictor Survey, MIS Mlri indictor Survey, N number of pregnnt women Dt not vilble

10 Pge 10 of 12 Tble 8 Proportion of households owning t lest one insecticide-treted bed net but with fewer thn one net for every two household members (intr-ownership gp) DHS 2003 MICS 2006 DHS 2010 MIS 2014 Percentge point chnge ( ) Urbn 60.8 ( ) ( ) ( ) ( ) ( ) Rurl 74.4 ( ) ( ) ( ) ( ) ( ) Household welth quintiles Poorest 67.0 ( ) ( ) ( ) ( ) ( ) Poorer 90.5 ( ) ( ) ( ) ( ) ( ) Averge 80.4 ( ) ( ) ( ) ( ) ( ) Richer 79.4 ( ) ( ) ( ) ( ) ( ) Richest 59.2 ( ) ( ) ( ) ( ) ( ) Smll (1 5 members) 45.2 ( ) ( ) ( ) ( ) ( ) Medium (6 8 members) 87.9 ( ) ( ) ( ) ( ) ( ) Lrge (9+ members) 97.5 ( ) ( ) ( ( ) ( ) CI Confidence intervls, DHS Demogrphic nd Helth Survey, MICS Multiple Clusters Indictor Survey, MIS Mlri indictor Survey, N number of households Tble 9 Proportion of individuls with ccess to n insecticide-treted bed net who did not use them the night before the survey (behviourl gp) DHS 2003 MICS 2006 DHS 2010 MIS 2014 Urbn 31.0 ( ) 12, ( ) 21, ( ) 6733 Rurl 9.6 ( ) 46, ( ) 58, ( ) 31,660 Household welth quintiles Poorest 0.0 b ( ) 10, ( ) 15, b ( ) 8380 Poorer 8.9 ( ) 11, ( ) 15, ( ) 8495 Averge 17.8 ( ) 14, ( ) 16, ( ) 8520 Richer 16.9 ( ) 10, ( ) 16, ( ) 8165 Richest 26.6 ( ) 12, ( ) 16, ( ) 4833 Smll (1 5 members) 24.6 ( ) 14, ( ) 27, ( ) 11,250 Medium (6 8 members) 23.0 ( ) 16, ( ) 26, ( ) 12,025 Lrge (9+ members) 16.3 ( ) 28, ( ) 26, ( ) 15,118 CI Confidence intervls, DHS Demogrphic nd Helth Survey, MICS Multiple Clusters Indictor Survey, MIS Mlri indictor Survey, N number of individuls Dt not vilble b Negtive gp vlues were set to zero quintile of the popultion more frequently owned enough bed nets thn households locted in rurl settings or with lower welth index. This result is consistent with the findings of other studies showing tht ITN coverge is lower in urbn res becuse mss distribution cmpigns usully focus on rurl communities [29, 30]. Therefore, future strtegies for ITN distribution should py prtiuclr ttention to urbn res. Overll, the behviourl gp ws very low in However, households locted in urbn settings nd from the richest quintile of welth index hve higher gps, becuse they might hve other lterntive prevention

11 Pge 11 of 12 DHS 2003 MICS 2006 DHS 2010 DHS 2014 Legend % 80-90% 70-80% 60-70% 50-60% b 40-50% 30-40% 20-30% 10-20% 0-10% Fig. 4 Trends of ownership nd behviourl gps between 2003 nd 2014, Burkin Fso. The proportion of households owning t lest 1 ITN but less thn 1 for every 2 members () nd the proportion of people with ccess to ITN but who did not use it the night before the survey (b) is indicted for ech region, for 2003, 2006, 2010 nd 2014 respectively methods, such s better housing. Also, behviourl gp ws significntly lower for lrge households which could result from lrge households hving more fmily members (especilly children) sleeping under the sme bed net. The results showed tht only few lrge households possessed enough bed nets to protect ll fmily members. This study hs few limittions, however, they do not ffect the vlidity of the results. This study ws bsed on exiting dt, nd ws limited by vilble dt. Survey dt were collected during different sesons of the yer. MIS dt were collected during the high trnsmission period while DHS dt were collected during the end of the trnsmission period. This difference could potentilly ffect the trends nlysis nd my hve under- or overestimted the effect size, s ITN use cn be sesonl depending on the perceived nuisnce of mosquitoes [31]. Furthermore, the mesures presented in this pper were self-reported nd therefore susceptible to socil desirbility bises. Conclusion Following the two free mss distribution cmpigns in 2010 nd 2013, Burkin Fso hs mde considerble progress in coverge of ITN ownership, ccess nd use between 2003 nd However, bed net coverge remins below ntionl trgets of 100% for ownership nd 80% for use. To reduce significntly the mlri burden in Burkin Fso, the NMCP needs to increse further nd sustined ITN ownership nd use in the generl popultion. The free mss distribution cmpigns contributed effectively to increse INT ownership nd use in Burkin Fso. The NMCP should continue implementing these cmpigns to rech the universl coverge trget. In ddition, these cmpigns should be complemented by other bed net distribution mechnisms (through ntentl cre, immuniztion) to identify nd replce nets tht re worn, dmged or lost between free mss distribution cmpigns. Furthermore, NMCP should hve n effective behviour chnge communiction component in ll distribution mechnisms to ensure tht the popultion use bed nets consistently. Abbrevitions ANC: ntentl cre; RBM: Roll Bck Mlri; BBC: behviour chnge communiction; DHS: Demogrphic nd Helth Surveys; EA: enumertion res; LLINs: long-lsting insecticidl nets; MERG: Monitoring nd Evlution Reference Group; MICS: Multiple Indictor Cluster Surveys; MIS: Mlri Indictor Survey; ITNs: insecticide-treted bed nets; NMCP: ntionl mlri control progrmme; SSA: sub-shrn Afric; WHO: World Helth Orgniztion. Authors contributions FKS nd SS conceived the study. SS nd MP performed the sttisticl nlysis. SS, FKS nd MP drfted the mnuscript. FKS nd YY contributed to the mnuscript by giving substntil intellectul inputs. All uthors red nd pproved the finl mnuscript. Author detils 1 Pôle Epidémiologie et Biosttistique, Institut de Recherche Expérimentle et Clinique (IREC), Fculté de Snté Publique (FSP), Université ctholique de Louvin (UCL), Clos Chpelle ux chmps 30, bte B , 1200 Bruxelles, Belgium. 2 Sptil Epidemiology Lb (SpELL), Université Libre de Bruxelles, Brussels, Belgium. 3 ICF, 530 Gither Rod, Suite 500, Rockville, MD, USA. 4 Centre de Recherche en Epidémiologie, Biosttistiques, et Recherche Clinique, Université Libre de Bruxelles, Brussels, Belgium. 5 Plte Forme Biosttistiques, Pôle Snté, Université Libre de Bruxelles, Brussels, Belgium. Competing interests The uthors declre tht they hve no competing interests.

12 Pge 12 of 12 Publisher s Note Springer Nture remins neutrl with regrd to jurisdictionl clims in published mps nd institutionl ffilitions. Received: 25 April 2017 Accepted: 18 July 2017 References 1. White MT, Conteh L, Cibulskis R, Ghni AC. Costs nd cost-effectiveness of mlri control interventions systemtic review. Mlr J. 2011;10: Lengeler C. Insecticide-treted bed nets nd curtins for preventing mlri. Cochrne Dtbse of Syst Rev. 2004;2:CD Eisele TP, Lrsen D, Steketee RW. Protective efficcy of interventions for preventing mlri mortlity in children in Plsmodium flciprum endemic res. Int J Epidemiol. 2010;39(Suppl 1):i O Mer WP, Mngeni JN, Steketee R, Greenwood B. Chnges in the burden of mlri in sub-shrn Afric. Lncet Infect Dis. 2010;10: Steketee RW, Cmpbell CC. Impct of ntionl mlri control scle-up progrmmes in Afric: mgnitude nd ttribution of effects. Mlr J. 2010;9: WHO. World mlri report Genev: World Helth Orgniztion. report/en/. 7. 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