ITN Access and Use Report Hannah Koenker and Emily Ricotta May 24, 2016

Transcription

1 ITN Access and Use Report Hannah Koenker and Emily Ricotta May 24, 2016

2 This report is 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: AID-OAA-A The contents do not necessarily reflect the views of USAID or the United States Government. Recommended citation: Koenker H, Ricotta E. May Insecticide-Treated Nets (ITN) Access and Use Report. Baltimore, MD. PMI VectorWorks Project, Johns Hopkins Center for Communication Programs. ITN Use and Access Report May 24,

3 Table of Contents Abbreviations... 5 May 2016 Update... 5 Key findings across PMI focus countries... 5 Background... 6 Definitions... 6 Methods... 6 Results... 8 PMI Focus Countries Angola Benin Burma Cambodia DRC Ethiopia Ghana Guinea Kenya Lao PDR Liberia Madagascar Malawi Mali Mozambique Nigeria Rwanda Senegal Tanzania Uganda Vietnam Zambia Zimbabwe Appendix: Non PMI-Focus Countries Burkina Faso Burundi Cameroon Central African Republic Chad Comoros Republic of Congo (Brazzaville) Cote d Ivoire Gabon Gambia Guyana Haiti Mauritania Namibia Niger Sao Tome Sierra Leone ITN Use and Access Report May 24,

4 Suriname Swaziland Timor Leste Togo ITN Use and Access Report May 24,

5 Abbreviations MICS ITN IRS LLIN PMI Demographic and Health Survey Multiple Cluster Indicator Survey Malaria Indicator Survey Insecticide-treated net Indoor Residual Spraying Long-lasting insecticidal net President s Malaria Initiative May 2016 Update As of May 24, 2016, non-pmi countries are included in the second half of the report. Previously reported DRC MICS 2010 and Ghana MICS results were updated after an error was discovered in the categorization of which nets were ITNs. MICS results for all countries have been added where available. This report now contains results from 81 household surveys in 41 countries. Questions and comments can be directed to hkoenker@jhu.edu for inclusion in subsequent updates of this report. Key findings across PMI focus countries Overall All but 6 PMI countries have the majority of their regional use:access ratios above 80%. Three countries, Mozambique, Senegal and Guinea, have a mix of regions at the red, yellow, and green categories, with specific regions showing that low use of available nets is likely due to dry season, higher altitude, and/or lower prevalence. Four countries appear to have below target use:access ratios over most of the country: Ghana, Nigeria, Senegal, and Zimbabwe. Senegal s use:access appears, however, to be highly seasonally driven. Zimbabwe and Nigeria have the lowest use:access ratios, looking at the most recent datasets. Additional research in Nigeria indicates that zonal and seasonal influences contribute to larger net use variations in some areas of the country. ITN access remains well below target for the majority of countries, indicating more nets are needed to fill gaps within households. Wealth Quintiles Five countries (Ghana, Guinea, Nigeria, Senegal, and Zimbabwe) show below-target use:access ratios when viewed by wealth quintile. Of the 18 countries with available data, six demonstrate a mild pro-poor trend in use:access ratios, with poorest households having better use of available nets compared to richer households. Of these six, all are above the 80% targets. The remaining 12 countries show no observable differences in use:access among wealth quintiles. Nigeria shows a pro-rich trend in use:access in, but pro-poor trends in the previous two surveys. ITN Use and Access Report May 24,

6 Urban/Rural There are no programmatic differences in urban/rural use:access ratios, apart from Ghana, where mean use:access is 0.44 in urban areas and 0.74 in rural areas, and in Mozambique, where urban areas have moderately better use:access (0.85) compared to rural areas (0.77). Use of ITNs in IRS and non-irs households Use:access ratios are not programmatically different between sprayed and unsprayed households. Background National results for ownership, access, use, and the use:access ratio have been described in Koenker et al previously in detail 1. However, national results conceal variations by region, which may result from differences in survey timing vis à vis rainy season (among other reasons). Variations in other subgroups such as wealth quintile or urban/rural residence may offer ways to identify target groups that do not use their available nets to the fullest degree. Definitions Ownership : household ownership of at least 1 ITN. Ownership indicator provides an estimate of the minimum threshold for ITN coverage if the household has at least one. However, ownership does not take into account whether the household has enough nets for all family members. Access : the proportion of the population with their household. Also called population access or ITN access. This indicator is calculated based on the number of ITNs in the household and the number of household members. Over a large sample, it calculates the proportion of people who should have (in principle, based on the assumption that one ITN can be used by two people in the household) an ITN to sleep under. It cannot be calculated on an individual basis. Use : the proportion of the population that slept under an ITN the night before the survey. Also called population use to distinguish it from use of ITNs by children under five or pregnant women. Use:access ratio : the result when dividing use by access (i.e. use/access). Gives an estimate of the proportion of the population using nets, among those that have access to one within their household. As it is a ratio, it is not technically a percentage, although it can be interpreted as such. This indicator provides data on the behavioral gap for net use rather than a use gap because not enough nets are available. Methods For each dataset three indicators were calculated: individual access to ITN within the household, individual use of ITN the previous night, and household ownership of at least one ITN. The ratio of population ITN use to population ITN access within the household was calculated and is referred to here as the use:access ratio. 1 Koenker H, Kilian A (2014) Recalculating the Net Use Gap: A Multi-Country Comparison of ITN Use versus ITN Access. PLoS ONE 9(5): e doi: /journal.pone ITN Use and Access Report May 24,

7 ITN use was calculated in the household member file, as was access to an ITN. This appropriately weights the access ratio for each household according to the number of members in each household. (Running the access calculation and calculating the mean within the household file does not take into account the number of people in each household, making that result an unweighted mean.) However, ITN ownership is calculated within the household file. Data management and analysis was done using Stata 14 (Stata Corporation, College Station, Texas, USA). All analyses accounted for survey design including sampling weights where applicable using the survey command family in Stata. The survey indicator of access to ITN within the household was calculated from the datasets of individual household members as recommended by MERG 2. First, an intermediate variable of potential ITN users was created by multiplying the number of ITN in each household by a factor of 2.0. In order to adjust for households with more than one net for every two people, the potential ITN users were set equal to the defacto population in that household if the potential users exceeded the number of people in the household. Second, the population access indicator was calculated by dividing the potential ITN users by the number of de-facto members for each household and determining the overall sample mean of that fraction. Use of an ITN the previous night was calculated for each de facto member of the household, i.e. those present in the house the previous night, as recommended by MERG using the listings of net users from the net roster 2. Household ownership of at least one ITN was also calculated for each dataset based on the number of ITN observed in the household and defining an ITN as a long-lasting insecticidal net (LLIN) identified by its label or a net that was treated with an insecticide within the last 12 months. Access, use, and ownership were stratified by region, by rural/urban status (residence), wealth quintile, and where available, whether the household had received IRS in the last 12 months for each country. Cluster weighted univariate regressions were conducted to assess whether significant differences existed between strata. 2 MEASURE Evaluation, MEASURE, President's Malaria Initiative, Roll Back Malaria Partnership, UNICEF, et al. () Household survey indicators for malaria control. ITN Use and Access Report May 24,

8 Results National results for ownership, access, use, and the use:access ratio have been described in Koenker et al in detail (Koenker, 2014), and national results for all countries are presented below in Table 1 for quick reference. However, national results conceal variations by region, which may result from differences in survey timing in regards to rainy season. Regional or provincial results, indicators by wealth quintile and by urban or rural residence are presented below for each country where data is available. Results for ratio of use:access are color-coded as follows: Note 1: Color coding of use:access ratios and explanation <0.80 <0.60 Use:access ratio is good, with at least 80% of those with access to an ITN using one the previous night Use:access ratio is below target level; improvements should be made Use:access ratio is poor; explore reasons for non-use of available nets, such as dry season, low-transmission area, and IRS activities. Table 1: National results for ITN ownership, access, use, and use:access ratio in PMI Focus Countries % of population % of population % of households with access to an that used an ITN Country Survey Year owning 1 ITN ITN within their the previous own household night Ratio of use:access Angola % 14.5% 11.9% 0.82 Angola 34.5% 19.0% 18.9% 0.99 Benin % 14.7% 14.7% 1.00 Benin % 64.0% 62.6% 0.98 Cambodia % 3.1% 3.0% 0.96 DRC % 4.2% 4.3% 1.03 DRC MICS % 30.1% 30.9% 1.03 DRC % 46.5% 50.2% 1.08 Ghana 41.7% 30.1% 20.9% 0.69 Ghana MICS 49.3% 38.0% 27.8% 0.73 Ghana % 59.0% 35.7% 0.60 Guinea % 1.5% 1.1% 0.77 Guinea % 25.3% 18.9% 0.75 Kenya 55.7% 42.3% 35.1% 0.83 Kenya % 48.2% 42.6% 0.88 Kenya % 52.5% 47.6% 0.91 Lao MICS % 40.2% 40.9% 1.02 Liberia % 25.4% 22.8% 0.90 Liberia 49.7% 30.8% 32.1% 1.04 Liberia 54.6% 37.0% 31.7% 0.86 Madagascar 57.0% 34.7% 36.6% 1.05 Madagascar 80.5% 57.3% 68.4% 1.19 Madagascar 69.2% 47.8% 55.0% 1.15 ITN Use and Access Report May 24,

9 Malawi % 37.6% 29.0% 0.77 Malawi % 37.2% 40.9% 1.10 Malawi MICS % 56.6% 53.9% 0.95 Malawi % 51.8% 52.5% 1.01 Mali % 29.7% 21.4% 0.72 Mali A&P % 61.6% 56.2% 0.91 Mali 84.4% 65.1% 60.4% 0.93 Mozambique 54.7% 37.0% 29.4% 0.80 Nigeria 8.0% 4.8% 3.2% 0.68 Nigeria % 28.7% 23.3% 0.81 Nigeria MICS 41.1% 28.6% 12.3% 0.29 Nigeria 49.5% 36.1% 12.9% 0.36 Rwanda % 38.1% 39.7% 1.04 Rwanda % 64.2% 57.7% 0.90 Rwanda 82.6% 65.9% 60.9% 0.92 Senegal 60.4% 34.9% 22.9% 0.66 Senegal % 38.1% 28.9% 0.76 Senegal c % 57.4% 40.7% 0.71 Senegal c % 58.4% 40.4% 0.69 Tanzania TH % 25.4% 20.3% 0.80 Tanzania % 46.6% 45.1% 0.97 Tanzania TH 90.9% 74.5% 68.4% 0.92 Uganda % 31.6% 25.6% 0.81 Uganda 59.8% 44.7% 35.0% 0.78 Uganda % 78.8% 68.6% 0.87 Zambia % 33.9% 23.0% 0.68 Zambia % 46.6% 34.9% 0.75 Zimbabwe % 4.8% 2.4% 0.50 Zimbabwe % 20.2% 8.7% 0.43 Zimbabwe MICS % 34.0% 24.1% 0.71 ITN Use and Access Report May 24,

10 Table 2: National results for ITN ownership, access, use, and use:access ratio in non PMI-Focus countries % of % of population % of population Country Survey Year households with access to an that used an Ratio of owning 1 ITN within their ITN the use:access ITN own household previous night Burkina Faso % 36.1% 31.5% 0.87 Burundi % 39.1% 37.8% 0.97 Burundi % 46.0% 48.6% 1.06 Cameroon 18.3% 10.8% 7.6% 0.71 Central African Republic MICS % 31.1% 33.3% 1.07 Chad MICS % 27.7% 9.2% 0.33 Comoros % 41.2% 38.3% 0.93 Congo (Brazzaville) % 22.6% 26.0% 1.15 Cote d Ivoire % 49.0% 33.2% 0.68 Gabon % 26.9% 26.7% 0.99 Gambia 68.9% 45.3% 36.9% 0.82 Guyana % 22.3% 21.1% 0.95 Haiti % 10.8% 7.1% 0.65 Mauritania MICS 43.5% 24.2% 15.1% 0.62 Namibia % 12.8% 5.5% 0.43 Namibia 24.4% 18.1% 3.9% 0.22 Niger % 19.6% 4.4% 0.22 Niger % 37.3% 13.8% 0.37 Sao Tome 60.8% 51.0% 45.9% 0.90 Sierra Leone 36.6% 19.2% 18.8% 1.02 Sierra Leone MICS % 18.2% 20.7% 1.13 Sierra Leone 64.4% 37.7% 41.8% 1.11 Suriname MICS % 4.7% 4.1% 0.89 Swaziland % 2.3% 0.3% 0.11 Swaziland MICS % 7.6% 1.1% 0.15 Timor Leste % 25.5% 29.2% 1.14 Togo MICS % 38.0% 34.6% 0.91 Togo 65.4% 48.8% 33.6% 0.69 ITN Use and Access Report May 24,

11 PMI Focus Countries Angola Two surveys were available in Angola, the and the. Rains in the south are from February through April. In the north, rain is from October to May. The northernmost parts of Angola experience rain throughout most of the year. The survey took place from November, 2006 through March, Fieldwork for the was completed January through May,. In , 101 of 2,599 households reported being sprayed with IRS (4%); in, 505 of 8,030 households reported spraying (6%). An integrated measles/itn campaign for children under 5 was done in A subnational universal coverage campaign was done in. Angola s universal coverage campaign began in and continued into (Angola MOP FY15) % of households owning % of population that used 1 ITN an ITN the previous night Region Stable Mesoendemic 20% 36% 11% 19% 10% 21% Hyperendemic 51%* 30% 30%* 17% 25%* 17% Instable Mesoendemic 23% 37% 12% 20% 8% 19% Luanda 23% 35% 11% 19% 9% 17% Wealth Quintile Poorest 26% 15%* 15% 8%* 13% 9%* Poorer 22% 23%* 12% 11%* 10% 13%* Middle 32% 33%* 16% 17%* 15% 18%* Richer 28% 42%* 14% 23%* 11% 22%* ITN Use and Access Report May 24,

12 % of households owning % of population that used 1 ITN an ITN the previous night Richest 31% 44%* 16% 24%* 9% 23%* Residence Urban 29% 39% 15% 22% 11% 20% Rural 26% 32%* 14% 17%* 13% 18% IRS No 27% 34% 15% 18% 12% 18% Yes 34% 46%* 13% 27%* 6% 28%* *p-value 0.05 compared to reference group (denoted with ) Observations While the use:access ratio has been generally high in Angola, the survey saw all regions, wealth quintiles, and residences increase their ratio above.80. Access and use both increase significantly as wealth increases. While urban residences have higher net access, there is no significant difference in use between the categories. In the 2006 survey, there was no significant difference in net use or access between households who had reported IRS and those who had not. In, households with IRS had significantly higher access and use than those without. As of, overall access to ITNs was very low. Implications for programming While access to ITNs is quite low, use of these ITNs is high across Angola. ITN distribution should be increased, and SBCC should be continued throughout the country to maintain the very high use:access ratio here. ITN Use and Access Report May 24,

13 Benin Available data for Benin include the 2006, conducted primarily in September 2006, at the end of the Northern Benin rainy season and just before rains started in the south, and the -2012, conducted in Littoral in September, just prior to rainy season there, with most fieldwork done in remaining regions in January-March 2012, during their cooler/drier season. In -12, 1,289 households reported being sprayed with IRS, of 17,422 (7%). Benin implemented an under 5 campaign in 2007 and a universal coverage campaign in and 2014 (Benin MOP FY15) % of households owning % of population that used 1 ITN an ITN the previous night Province Alibori 8% 89% 3% 68% 3% 68% Atacora 26%* 93%* 14% 77%* 13% 66% Atlantique 13%* 75%* 9% 60%* 9% 62% Borgou 20%* 81%* 10% 62%* 10% 59% Collines 30%* 78%* 19% 62%* 19% 60% Couffo 29%* 82%* 15% 62%* 15% 60% Donga 30%* 84% 14% 64% 13% 61% Littoral 28%* 78%* 22% 65% 23% 64% Mono 25%* 74%* 16% 60%* 16% 60% Oueme 34%* 74%* 21% 58%* 22% 59% Plateau 21%* 84% 14% 68% 13% 68% Zou 27%* 79%* 16% 62%* 17% 65% SES Poorest 11% 79% 6% 62% 7% 61% Poorer 17%* 81% 9% 64% 10% 63% Middle 24%* 80% 13% 63% 14% 62% Richer 31%* 78% 18% 64% 17% 61% ITN Use and Access Report May 24,

14 % of households owning % of population that used 1 ITN an ITN the previous night Richest 39%* 80% 27% 67%* 26% 65%* Residence Urban 29% 78% 19% 64% 19% 62% Rural 21%* 81%* 12% 64% 12% 63% IRS No 79% 63% 62% 0.98 Yes 94%* 79%* 70%* 0.89 *p-value 0.05 compared to reference group (denoted with ) Observations Overall, the ratio between ITN access and ITN use is excellent in Benin, indicating that those who have nets available are using them. There was no significant change between 2006 and 2012 in the ratio, although there was a slight pro-poor trend when looking at wealth quintile in 2006 and the use:access ratio, which disappeared in In 2006 in general there was a pro-rich trend to ITN ownership, access, and use, although this hid the pro-poor trend in the use:access ratio. By 2012 access and use was relatively consistent among wealth quintiles. In the same vein, in 2006 and 2012 there were differences between urban and rural ownership of nets, but there was no significant difference in access and use. Again the ratio of use:access remained stable between the subgroups and surveys. There was no IRS data collected in the 2006 survey, but the 2012 survey demonstrated that those households with IRS were had significantly higher ownership, access, and use than those without. However, the use to access ratio was higher in the non-irs group than the IRS group. Implications for programming Overall improvements in ownership and access appear to reduce disparities among wealth quintiles in Benin, and between urban and rural residents. There is no clear need for prioritizing SBCC messages in certain regions over others; all regions have a use:access ratio of over Additional work may be helpful to determine whether dry-season net use and transmission patterns warrant increased SBCC during lower-net use seasons. ITN Use and Access Report May 24,

15 Burma The Myanmar 2015 contains the malaria module but is not yet released. ITN Use and Access Report May 24,

16 Cambodia Cambodia s 2005 contains information on malaria and ITNs; its 2010 and 2014 surveys do not. Cambodia implemented mass ITN distribution in Region % of households owning 1 ITN 2005 % of population that used an ITN the previous night Banteay Mean Chey 4.9% 3.1% 3.5% 1.10 Kampong Cham 4.7% 3.8% 3.0% 0.78 Kampong Chhnang 3.5% 2.3% 2.3% 0.97 Kampong Speu 0.5%* 0.2%* 0.4%* 1.66 Kampong Thom 6.4%* 4.1% 4.3% 1.04 Kandal 0.4%* 0.2%* 0.1%* 0.94 Kratie 18.8%* 13.4%* 11.6%* 0.87 Phnom Penh 0.2%* 0.1%* 0.0%* 0.50 Prey Veng Pursat 0.3%* 0.1%* 0.1%* 1.28 Siem Reap 2.8% 1.9% 1.3% 0.69 Svay Rieng Takeo 0.3%* 0.2% 0.0%* 0.20 Otdar Mean Chey 30.4%* 20.8%* 26.3%* 1.26 Battambang & Krong Pailin 6.0% 3.7%* 3.6% 0.97 Kampot & Krong Kep 3.6% 2.5% 2.4% 0.97 ITN Use and Access Report May 24,

17 Krong Preah Sihanouk & Kaoh Kong Preah Vihear & Steung Treng Mondol Kiri & Rattanak Kiri % of households owning 1 ITN 2005 % of population that used an ITN the previous night 11.4%* 6.7% 7.6% %* 32.3%* 30.1%* %* 26.5%* 29.3%* 1.11 Wealth Quintile Poorest 9% 6% 6% 1.00 Poorer 6%* 4%* 4% 0.96 Middle 4%* 3%* 3%* 0.97 Richer 2%* 2%* 1%* 0.85 Richest 1%* 1%* 1%* 0.89 Residence Urban 2% 1% 1% 0.94 Rural 5%* 3%* 3%* 0.97 Observations Cambodia had an excellent ratio of use:access in 2005, with lower rates in specific regions. Implications for programming Given the time elapsed since this survey, no programming implications are noted here. ITN Use and Access Report May 24,

18 DRC Available data for DRC include the, the 2010 MICS, and the The was conducted primarily in December-January , during the rainy season (excepting the provinces north of the equator, Oriental and Equatorial, where it was dry). The 2010 MICS was conducted in January-February 2010, also during rainy season in the southern part of the country. The 2007 was fielded from February to July. No IRS data was included in any of the surveys. DRC implemented universal coverage campaigns in and in MICS MICS MICS MICS % of households owning 1 ITN access to an ITN within % of population that used an ITN the previous night Province Kinshasa 16% 52% 59% 8% 29% 37% 8% 35% 39% Bandundu 12% 42% 88%* 5% 23% 63%* 5%* 24%* 70%* Bas-Congo 35%* 66%* 76%* 18%* 37%* 51%* 18%* 41% 58%* Equateur 4%* 28%* 83%* 2%* 13%* 57%* 2%* 14%* 63%* Kasai- Occidental 7%* 19%* 58% 3%* 9%* 31% 3%* 9%* 31%* Kasai- Oriental 6%* 36%* 64% 2%* 20%* 38% 2%* 24%* 43% Katanga 8%* 72%* 80%* 4%* 44%* 55%* 5%* 39% 57%* Maniema 13% 85%* 59% 6% 64%* 37% 6%* 52%* 40% Nord-Kivu 4%* 51% 60% 2%* 26% 39% 2%* 27% 39% Orientale 3%* 72%* 47%* 2%* 51%* 33% 2%* 45% 35% Sud-Kivu 6%* 50% 70%* 3%* 26% 46%* 3%* 32% 51%* Wealth Quintile ITN Use and Access Report May 24,

19 MICS MICS MICS MICS % of households owning 1 ITN access to an ITN within % of population that used an ITN the previous night Poorest 3% 41% 59% 1% 24% 39% 1% 25% 42% Poorer 6%* 49%* 72%* 3%* 28%* 48%* 3%* 29% 53%* Middle 10%* 49%* 75%* 4%* 28%* 50%* 5%* 29% 55%* Richer 11%* 53%* 77%* 5%* 30%* 52%* 5%* 32%* 55%* Richest 16%* 67%* 68%* 7%* 41%* 44%* 8%* 39%* 46% Residence Urban 12% 58% 71% 6% 35% 46% 6% 34% 48% Rural 7%* 48%* 70% 3%* 28%* 47% 3%* 29% 51% *p-value 0.05 compared to reference group (denoted with ) Observations The MICS and data show that there are no particular provinces where ITN use among those with access is worrisome. Nor is ITN use:access ratio related to socio-economic status, or residence. Overall, rates of ITN use are extremely good throughout DRC, assuming nets are available. Implications for programming There is a need for additional nets to fill gaps at the household level in population access to ITNs; SBCC programming for net use does not appear to need to be targeted to certain areas over others. ITN Use and Access Report May 24,

20 Ethiopia The most recent available survey, the, does not contain the malaria module. The dataset for the is not available publicly, but ownership results are reported here from the survey report 3. An was fielded in late 2015, with funding from PMI and Global Fund, but is not yet available. Ethiopia implemented mass campaigns in 2007, 2010,, but with ongoing large scale ITN distribution since 2005 in all years. % of households owning 1 ITN Province Amhara 73.6 B. Gumuz & Gambella 69.0 Diredawa 78.9 Oromia 43.7 SNNPR 57.0 Somali & Afar 45.0 Tigray 65.8 % of population that used an ITN the previous night Ratio of use:access Wealth Quintile Poorest 44.2 Poorer 52.4 Middle 54.6 Richer 31.2 Richest 66.4 Residence 3 Ethiopia National Malaria Indicator Survey,. Report.pdf ITN Use and Access Report May 24,

21 % of households owning 1 ITN Elev <2000m 54.8 Elev >2000m 37.6 % of population that used an ITN the previous night Ratio of use:access ITN Use and Access Report May 24,

22 Ghana Available data for Ghana include the, conducted primarily in September and October, during rainy/high transmission season; the MICS, conducted in September-November, also during rainy/high transmission season; and the 2014, conducted from early September through mid December 2014, in rainy/high transmission season. Questions on IRS were not included in the and surveys. In 2014, 2,157 households reported spraying with IRS, of 11,835 (18%). Ghana implemented mass distributions in 2006-, -2012, and MICS 2014 MICS 2014 MICS 2014 MICS 2014 % of households owning % of population that used 1 ITN an ITN the previous night Region Western 41% 43% 67% 30% 32% 59% 20% 23% 38% Central 42% 32%* 70% 30% 21%* 58% 17% 17%* 42% Greater Accra 30%* 26%* 53%* 24%* 20%* 49%* 12%* 11%* 16%* Volta 43% 86%* 76%* 30% 79%* 70%* 22% 65%* 54%* Eastern 36% 78%* 73% 26% 71%* 64% 19% 49%* 38% Ashanti 40% 40% 70% 28% 28% 60% 19% 22% 34% Brong Ahafo 51%* 54%* 81%* 36%* 34% 70%* 32%* 27% 52%* Northern 54%* 67%* 71% 31% 43%* 55% 23% 27% 36% Upper East 53%* 52% 73% 37% 34% 56% 26%* 28% 31% Upper West 71%* 61%* 77%* 50%* 39%* 61% 42%* 31%* 38% Wealth Quintile Poorest 50% 66% 80% 32% 45% 60% 28% 38% 46% Second 46% 59%* 78% 32% 43%* 64% 25% 36% 50% ITN Use and Access Report May 24,

23 MICS 2014 MICS 2014 MICS 2014 MICS 2014 % of households owning % of population that used 1 ITN an ITN the previous night Middle 40%* 52%* 70%* 29% 41%* 61% 21%* 30%* 39%* Fourth 36%* 42%* 63%* 27%* 32%* 56%* 17%* 21%* 25%* Richest 39%* 35%* 58%* 30% 29%* 54%* 14%* 14%* 18%* Residence Urban 35% 40% 60% 26% 31% 54% 15% 19% 24% Rural 48%* 60%* 78%* 34%* 45% 64%* 26%* 36%* 47%* IRS No 49% 68% 38% 59% 36% 36% Yes 47% 72% 36% 59% 19% 33% *p-value 0.05 compared to reference group (denoted with ) Observations Use given access is lowest in Greater Accra (0.32), and highest in Volta and Brong Ahafo in 2014 ( ). These last two regions also had the highest rates of intra-household access to nets in the 2014 (a pattern observed also in ). However, the range of use:access is fairly consistent across regions. Across the country, the ratio declined between and 2014, erasing gains made in the MICS. The largest drop was in Greater Accra. In, there was a large discrepancy in urban vs rural use:access ratios (0.56 vs 0.74), and the urban rates caught up to the rural rates in ; in 2014 we see again that rural households are using their nets more than urban households. may have been an anomaly, but access within both types of households was relatively good (>50%) in Low rates of use:access among urban households may simply reflect SES differences. A more dramatic change is seen in use:access ratios by wealth quintile. We observe a strong negative trend in and in 2014 from poorest to richest quintiles, indicating that the wealthiest households are not using nets they have. However, in, the use:access ratio had evened out completely among all five quintiles, probably reflecting gains in use in wealthier urban and peri-urban areas, despite a linear negative trend of population access itself in. It is again unclear whether this is a seasonal anomaly from (as with rural/urban trends), or reflects a decline in ITN Use and Access Report May 24,

24 net culture among the wealthiest since. Since each survey was done at generally the same time of year, it appears unlikely that year-to-year differences are due to seasonal changes, although more work is needed to confirm that rainfall and survey timing were equivalent in all years. There was no difference in net ownership, access, or use among households who had received IRS and those who had not; the use:access ratio is similarly low for both groups. Implications for programming There is no indication from these data that certain regions should be prioritized for SBCC messaging due to lower use:access ratios. Rather, the country as a whole has a use gap of roughly percentage points. ITN Use and Access Report May 24,

25 Guinea Available data for Guinea include the 2005, fielded January to June during dry season and early rains, and the 2012, which was conducted between June and August during Guinea s rainy season. Conakry fieldwork was done at the very beginning of rainy season. In households reported spraying with IRS, of 7,109 (1.7%). Guinea implemented an under-five campaign in 2009, and universal coverage campaigns in and in % of households owning 1 ITN access to an ITN within % of population that used an ITN the previous night Region Boké 3.9% 42% 1.7% 25% 1.0% 21% Conakry 7.6% 36% 3.5% 19%* 3.2% 13%* Faranah 3.4% 64%* 1.4% 31% 0.9% 26% Kankan 4.6% 51% 1.5% 26% 0.9% 25% Kindia 2.4% 42% 0.9% 21% 0.8% 14%* Labé 0.4% 62%* 0.3% 38%* 0.1% 18% Mamou - 53%* - 33%* - 12%* 0.38 Nzerekore 4.0% 45% 1.4% 23% 1.2% 22% Wealth Quintile Poorest 1.8% 49% 0.6% 27% 0.3% 20% Poorer 1.9% 48% 0.8% 26% 0.5% 21% Middle 3.0% 51% 1.2% 27% 1.0% 19% Richer 4.6% 49% 1.8% 27% 1.2% 20% Richest 6.7% 39%* 3.0% 20%* 2.8% 14%* ITN Use and Access Report May 24,

26 % of households owning 1 ITN access to an ITN within % of population that used an ITN the previous night Residence Urban 5.7% 42% 2.4% 22% 2.1% 17% Rural 2.7% 50%* 1.1% 27%* 0.7% 20% IRS No 47% 25% 19% 0.76 Yes 55% 29% 26% 0.90 *p-value 0.05 compared to reference group (denoted with ) Observations Regional variations in household ownership were present in 2012, with Conakry having the lowest rates of ownership. However, data was collected prior to the 2014 mass campaign, which undoubtedly increased coverage. Conakry, Kindia, and most especially Labe and Mamou regions had lower-than-targeted ratios of ITN use:access. Mamou and Labe are in the Fouta Djallon area, which have higher altitudes and cooler temperatures. These low ratios are contributing to the <0.80 ratios observed when looking at SES and at residence. As is observed in some other countries, there is a slight pro-poor trend towards better ITN use:access ratio. There was no difference in ITN ownership, access, or use among households having received IRS and those who did not, although households not receiving IRS had a lower use:access ratio (0.76 compared to 0.90). However, only 119 of 7,109 households reported being sprayed, mostly by private companies. Implications for programming Given the very low ITN use:access ratio in Mamou and Labe, further investigation would be useful to determine whether this is a result of seasonality or altitude (it would have been raining in Mamou at the time of data collection, usually contributing to better use rates) and/or behavioral barriers to net use. ITN Use and Access Report May 24,

27 Kenya Kenya has three national surveys and the -14 Regional MICS to include in this analysis. The was completed between November and February 2009, during the short rains. The -14 Regional MICS were completed between November and January, also during the short rains. The 2014 was completed between April and October, during the long rains. Kenya has rain periodically throughout the year, with short rains in November and December, followed by a dry season from December to March. Long rains occur from April through June, and it is cool and dry again from June through October. The 2010, implemented by DOMC, is not publically available. The 2015 was fielded in July-August 2015 (long rains), but does not include information on IRS. In -9, 617 households reported being sprayed with IRS, of 9,057 (7%). In 2014, 905 of 36,369 households reported IRS (2%). Kenya implemented mass ITN distributions in -12, and a rolling campaign in Region MICS % of households owning 1 ITN MICS MICS % of population that used an ITN the previous night MICS 2014 Nairobi 51% 44% 66% 47% 40% 62% 42% 38% 53% Central 33%* 38% 41%* 27%* 33%* 35%* 23%* 27%* 28%* Coast^ 66%* 69%* 72% 53% 58%* 58%* 46% 55%* 57% Eastern 60%* 56%* 62%* 44% 44% 46%* 35% 37% 39%* Nyanza^ 76%* 81%* 86%* 58%* 62%* 75%* 49% 61%* 71%* Rift Valley^ 41%* 56%* 54%* 29%* 44% 48%* 22%* 35% 42%* Western^ 71%* 82%* 79%* 51% 64%* 57%* 43% 58%* 55% Northeastern 73%* 49% 49%* 48% 34% 33%* 46% 30%* 34%* ITN Use and Access Report May 24,

28 MICS % of households owning 1 ITN MICS MICS % of population that used an ITN the previous night Regional MICS 4 Bungoma 78% 61% 57% 0.94 Kakamega 78% 63% 62% 0.98 Nyanza 5 92% Turkana 37% 22% 20% MICS Wealth quintile Poorest 49% 51% 49% 30% 36% 37% 26% 31% 34% Poorer 58%* 61%* 63%* 41%* 46%* 52%* 32%* 41%* 49%* Middle 60%* 64%* 68%* 42%* 52%* 56%* 35%* 46%* 51%* Richer 55% 57%* 62%* 46%* 51%* 55%* 37%* 45%* 49%* Richest 56% 61%* 68%* 52%* 56%* 62%* 45%* 50%* 54%* Residence Urban 58% 56% 62% 52% 49% 54% 47% 46% 49% Regional MICS in -14 were conducted in four areas of Kenya. Results are presented only for the regional estimates, and not for subanalyses below (wealth quintile etc). 5 The Nyanza regional MICS did not collect data on which household members stayed in the house the previous night, which is necessary for calculating ITN use and ITN access. ITN Use and Access Report May 24,

29 MICS % of households owning 1 ITN MICS MICS % of population that used an ITN the previous night MICS 2014 Rural 55% 61%* 63% 40%* 47% 52% 32%* 41%* 47% IRS No 55% 58% 42% 48% 35% 42% Yes 65%* 77%* 46% 62%* 37% 55%* *p-value 0.05 compared to reference group (denoted with ) ^ region received LLINs in the mass campaign. Observations Kenya has a relatively high use:access ratio throughout the country and across wealth quintiles and residences, with improvement over the last three available surveys which may be due in part to survey timing. Both access and use increase with increasing wealth, however, use:access ratio is similar across all wealth quintiles. Prior to 2015, urban residents had higher access and use than those in rural areas, but this has evened out in the 2015 survey. In both surveys, households receiving IRS had a higher proportion of ITN ownership, but use:access ratio was the same in both groups. Implications for programming Kenya is doing well in terms of the proportion of the population using nets when they have access to them. Continued net distributions and SBCC campaigns in areas targeted for ITNs will help in maintaining these high numbers. ITN Use and Access Report May 24,

30 Lao PDR The -12 MICS was fielded primarily from October to February, during the drier cooler season. Region % of households owning 1 ITN -12 MICS % of population that used an ITN the previous night Vientiane Capital 22% 18% 17% 0.94 Phongsaly 51%* 39%* 36%* 0.92 Luangnamtha 44%* 39%* 41%* 1.06 Oudomxay 86%* 74%* 80%* 1.08 Bokeo 50%* 38%* 41%* 1.06 Luangprabang 69%* 57%* 60%* 1.06 Huaphanh 38%* 32%* 30%* 0.93 Xayabury 49%* 45%* 48%* 1.06 Xiengkhuang 25% 21% 20% 0.94 Vientiane 29% 20% 16% 0.80 Borikhamxay 67%* 61%* 62%* 1.02 Khammuane 51%* 42%* 42%* 1.00 Savannakhet 48%* 38%* 37%* 0.99 Saravane 72%* 57%* 62%* 1.09 Sekong 75%* 61%* 64%* 1.05 Champasack 40%* 33%* 33%* 1.01 Attapeu 84%* 71%* 74%* 1.05 ITN Use and Access Report May 24,

31 Wealth Quintile % of households owning 1 ITN -12 MICS % of population that used an ITN the previous night Poorest 56% 42% 48% 1.13 Poorer 56% 46% 48% 1.05 Middle 54% 47% 47% 1.00 Richer 46%* 40%* 39%* 0.96 Richest 31%* 26%* 22%* 0.87 Residence Urban 35% 30% 29% 0.95 Rural with road 52%* 44%* 45%* 1.03 Rural without road 59%* 45%* 47%* 1.04 Observations Lao PDR has excellent use:access ratios indicating a strong culture of net use. There is a marked decline in ownership, access, and use among wealthier quintiles, but use of nets by those with access remains high in all socioeconomic quintiles. Urban households have lower rates of ownership, use, and access to ITNs, but similar use:access ratios those in rural areas. Implications for programming Messaging around net use does not appear to need to be targeted to specific groups based on this analysis, but further analysis by high-risk group would be useful. ITN Use and Access Report May 24,

32 Liberia The dry season in Liberia lasts from December to April, with the rains occurring between May and November. There were three surveys available in Liberia: the -2009, the, and the. The majority of fieldwork was completed from December to February of 2009 (dry season), from September to December (primarily rainy), and from March through July (both dry and rainy seasons), respectively. In the, 439 of 4,162 households reported being sprayed with IRS (10%); in, 943 of 9,333 (10%) reported IRS. Liberia conducted mass distribution on a rolling basis between and 2012, and a national campaign in Region % of households owning 1 ITN % of population that used an ITN the previous night Monrovia 34% 53% 17% 34% 14% 35% North Western 63%* 44% 69% 41%* 26%* 49% 34%* 29% 43% South Central 32% 36%* 47%* 16% 21%* 31%* 13% 22%* 26%* South Eastern A 60%* 61% 45%* 31%* 38% 28%* 30%* 41% 24%* South Eastern B 66%* 64%* 46%* 39%* 40% 27%* 31%* 36% 21%* North Central 57%* 51% 66% 30%* 31% 47% 28%* 34% 41% Wealth Quintile Poorest 48% 41% 53% 26% 24% 36% 22% 27% 31% Poorer 54% 53%* 64%* 32% 32%* 44%* 30%* 35%* 38%* Middle 52% 49%* 61%* 28% 30% 42%* 25% 32% 38%* Richer 43% 52%* 52% 22% 33%* 34% 21% 36%* 30% Richest 38% 54%* 43%* 19% 34%* 29%* 16% 30% 22%* ITN Use and Access Report May 24,

33 Residence % of households owning 1 ITN % of population that used an ITN the previous night Urban 42% 52% 50% 22% 34% 33% 20% 34% 28% Rural 52%* 47% 61%* 28%* 28%* 42%* 25% 30% 36%* IRS No 50% 54% 31% 36% 32% 31% Yes 48% 61%* 29% 44%* 29% 36% *p-value 0.05 compared to reference group (denoted with ); As Monrovia was not sampled in survey, North Western region was used as reference group. Observations Liberia has consistently had a very high net use:access ratio across the country. The only region in which this ratio is less than 0.80 is South Eastern B, whose ratio is All wealth quintiles with the exception of the wealthiest in the survey (0.76) were above Net access seems to be highest in the poorer wealth quintiles. Use is relatively similar among each category. In, households receiving IRS had a higher proportion of ITN ownership and access. There was no difference in proportion using an ITN nor in the use:access ratio between those receiving IRS and those without. Implications for programming Liberia is doing a very good job both in terms of access and use when compared to other countries. Continued net distributions and SBCC campaigns nationwide will help in maintaining these high numbers. ITN Use and Access Report May 24,

34 Madagascar Available data for Madagascar include the, the, and the. The fieldwork was conducted between November and July 2009, mainly during dry season but stretching into rainy season in some areas, while the two surveys were conducted primarily between February and April, prior to rainy season. In, 3,710 households out of 9,094 (46%) reported IRS; in, 3,014 of 8,574 (35%) reported IRS. The sampled 22 regions that did not match up directly with the sampled regions in the later surveys; as it is older data, the regional analysis is excluded in the table below. Madagascar implemented mass distributions in , 2012-, and % of households owning % of population that used 1 ITN an ITN the previous night Transmission Zone Equatorial 78% 95% 93% 51% 69% 71% 57% 84% 83% Tropical 78% 94% 73%* 51% 70% 48%* 53% 81% 57%* Sub-desert 70%* 93% 55%* 40%* 63%* 31%* 37%* 84% 43%* High Plateaux 38%* 36%* 25%* 22%* 23%* 16%* 22%* 24%* 13%* Region Antananarivo 45% 37% 31% 24% 33% 20% Fianarantsoa 72%* 66%* 48%* 46%* 60%* 54%* Toamasina 95%* 89%* 72%* 69%* 84%* 76%* Mahajanga 97%* 81%* 75%* 55%* 89%* 69%* Toliary 94%* 63%* 63%* 39%* 80%* 51%* Antsiranana 91%* 85%* 69%* 69%* 79%* 77%* Wealth Quintile ITN Use and Access Report May 24,

35 % of households owning % of population that used 1 ITN an ITN the previous night Poorest 65% 92% 71% 35% 62% 45% 39% 81% 59% Poorer 61%* 87%* 71% 36% 62% 49% 40% 77%* 58% Middle 51%* 83%* 73% 30%* 59% 50% 32%* 71%* 59% Richer 52%* 73%* 69% 32% 52%* 50% 33%* 60%* 54% Richest 56%* 69%* 60%* 40%* 51%* 45% 39% 52%* 45%* Residence Urban 60% 87% 80% 43% 67% 63% 44% 72% 67% Rural 56% 80%* 67%* 33%* 56%* 46%* 35%* 68% 54%* IRS No 90% 75% 66% 54% 80% 63% Yes 67%* 54%* 46%* 34%* 54%* 38%* *p-value 0.05 compared to reference group (denoted with ) Observations Madagascar is the PMI country with the highest observed ITN use:access ratios, rarely dipping below 1.00 except for 0.87 observed in Antananarivo in the, and 0.79 for the High-Plateaux transmission zone, also in. Madagascar also has a high average number of users per net, driving up their ratio of ITN use:access, in part due to relatively small houses where it is difficult to hang multiple ITNs for a 1:2 net-to-user ratio. There is a consistent trend towards poorer households having higher use:access ratios, perhaps due to smaller house size, as well as the general phenomenon of wealthier households having lower numbers of people per sleeping space. Since the trends in use:access ratios for the wealth quintiles have improved over time; this is not statistically significant for other subgroups (urban/rural or regionally), as ratios are already very high. Ratios tend to be higher in the rural areas than in urban areas, but are still excellent in urban areas. Households that did not receive IRS had better ITN ownership, access, and use; the use:access ratio of both those with and without IRS remains above 1.00 in both cases in all surveys. ITN Use and Access Report May 24,

36 Implications for programming In general, ITN use among those with access to a net within their household is excellent in Madagascar; further determinants of net use should become available through the HC3 Malaria Behavioral Survey very shortly. ITN Use and Access Report May 24,

37 Malawi Malawi has four surveys available for analysis. The 2010 was completed between June and September 2010, during the cool dry season. The 2012 was conducted on the edge of the hot wet season, in March and April (rains are variable in March and are mostly complete in April). The MICS was conducted primarily from December to March, during the hot wet season. The 2014 was conducted in May and June, during high transmission season (cool dry season). In 2010, 865 of 24,825 households reported IRS (3%); in 2012, 290 of 3,404 (8%) reported IRS; in the -14 MICS, 3,353 households reported being sprayed with IRS, of 26,713 (13%). In 2014, 210 of 3,405 households reported IRS (6%). Malawi implemented mass distributions in 2012 (after the ), and Region MICS 2014 % of households owning 1 ITN MICS 2014 access to an ITN within their own household MICS 2014 % of population that used an ITN the previous night MICS Northern 56% 64% 84% 78% 38% 44% 64% 60% 27% 43% 61% 54% Central 54% 57% 79%* 70%* 35% 39% 58%* 53% 27% 44% 59% 53% Southern 59% 51%* 76%* 68% 40% 33%* 54%* 48%* 31%* 37% 48%* 51% Wealth Quintile Poorest 41% 47% 67% 61% 24% 31% 44% 42% 18% 36% 43% 45% Poorer 51%* 54%* 77%* 66% 32%* 34% 52%* 46% 24%* 40% 52%* 48% Middle 58%* 54% 80%* 69%* 37%* 35% 56%* 47% 29%* 41% 54%* 51% Richer 61%* 57%* 82%* 78%* 40%* 37% 61%* 62%* 30%* 41% 56%* 60%* Richest 74%* 65%* 84%* 78%* 55%* 48%* 70%* 62%* 43%* 46%* 64%* 57%* Residence ITN Use and Access Report May 24,

38 MICS 2014 % of households owning 1 ITN MICS 2014 access to an ITN within their own household MICS 2014 % of population that used an ITN the previous night MICS Urban 64% 56% 79% 75% 47% 40% 65% 60% 38% 41% 61% 57% Rural 55%* 55% 78% 69% 36%* 37% 55%* 50%* 27%* 41% 53%* 52% IRS No 57% 54% 78% 71% 37% 36% 57% 52% 29% 40% 54% 52% Yes 68%* 64% 79% 66% 46%* 45%* 57% 50% 42%* 49% 56%* 54% *p-value 0.05 compared to reference group (denoted with ) Observations Malawi continues to have a very high use to access ratio across all categories and regions. The 2012 and 2014 was conducted during the rainy season, when people tend to report using their nets more consistently. Net ownership and access improve with higher wealth quintiles; however, use of nets, given access, is marginally better among the poorer quintiles. In earlier surveys, households having received IRS had higher ITN ownership, access, and use. By the 2014 survey, there was no significant difference between these groups. Implications for programming Malawi is doing a very good job both in terms of access and use when compared to other countries. Continued net distributions and SBCC campaigns nationwide will help in maintaining these high numbers. ITN Use and Access Report May 24,

39 Mali Available data for Mali include the 2006, the 2010 Anemia and Parasitemia survey, and the Fieldwork for the 2006 was conducted between April and August, with Bamako region split between April and October. Fieldwork for the 2010 A&P was done in the high transmission period, primarily in September and October (wealth index information was not collected). Fieldwork for the was done beginning in late November and into February, during the end of the transmission period and then the cooler season. The northern zone of Timbuktu, Gao, and Kidal was not sampled during the 2012-, for security reasons. In 2010, 82 households reported IRS (with no timeframe), of 1,617 (5%); in , 842 of 10,105 (8%) reported IRS in the last 12 months. Mali implemented a national under five campaign in, and universal coverage campaigns in -13 and A&P % of households owning 1 ITN A&P access to an ITN within their own household A&P % of population that used an ITN the previous night A&P Region Kayes 44% 90% 79% 27% 71% 58% 20% 62% 53% Koulikoro 42% 85% 81% 21% 57%* 61% 15% 50%* 56% Sikasso 47% 88% 88%* 25% 61% 67%* 20% 59% 63%* Segou 50% 87% 92%* 31% 63% 77%* 23% 59% 73%* Mopti 65%* 87% 85%* 41%* 65% 66%* 28% 62% 61%* Tombouctou 48% 85% 31% 64% 26% 55% Gao 45% 66%* 28% 44%* 17% 47% Kidal 29%* 55%* 15%* 28%* 1%* 16%* Bamako 54%* 86% 77% 34% 60%* 57% 25% 51%* 51% Wealth Quintile Poorest 52% 80% 28% 60% 20% 56% ITN Use and Access Report May 24,

40 A&P % of households owning 1 ITN A&P access to an ITN within their own household A&P % of population that used an ITN the previous night A&P Poorer 49% 86%* 28% 66%* 21% 61%* Middle 44%* 87%* 26% 67%* 19% 63%* Richer 49% 86%* 30% 67%* 21% 63%* Richest 57%* 84%* 36%* 65%* 26%* 59% Residence Urban 54% 87% 82% 33% 62% 63% 23% 55% 58% Rural 48%* 86% 85%* 28%* 61% 65% 21% 57% 61% IRS No 86% 84% 61% 64% 56% 60% Yes 91% 93%* 65% 74%* 60% 67%* *p-value 0.05 compared to reference group (denoted with ) Observations Between 2006 and 2010, the use:access ratio for almost all regions increased to above.80, and this was maintained through the survey. This pattern was the same for both wealth quintiles (when measured) as well as rural and urban sites. ITN ownership, use, and access tended to be higher as wealth increased, although this did not affect the use:access ratio, which was similar among all regions, wealth quintiles, and residencies. Households having received IRS had a higher proportion of all three variables in the survey, although the use:access ratio was very similar across IRS strata and survey. Implications for programming Net use and access seem to be high across Mali, and have been sustained since Net distribution and SBCC nationally should be continued throughout the country to maintain the very high use:access ratio here. ITN Use and Access Report May 24,