SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
February, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
Malaria is a life-threatening parasitic disease that affects approximately 40% of the world’s population (mostly in the poorest countries). Insecticide-treated bednets effectively prevent malaria. However, cost and other barriers can hinder possession and use of insecticide-treated bednets. Strategies to increase possession and use include providing bednets for free or reducing the cost, education about appropriate use of bednets, and providing incentives to encourage use of bednets.
Malaria is a life-threatening parasitic disease that affects approximately 40% of the world’s population (mostly in the poorest countries). Insecticide-treated bednets effectively prevent malaria. However, cost and other barriers can hinder possession and use of insecticide-treated bednets. Strategies to increase possession and use include providing bednets for free or reducing the cost, education about appropriate use of bednets, and providing incentives to encourage use of bednets.
People making decisions about prevention and treatment of malaria
Augustincic Polec L, Petkovic J, Welch V, et al. Strategies to increase the ownership and use of insecticide-treated bednets to prevent malaria. Cochrane Database Syst Rev 2015; 3: CD009186.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
One of the barriers to owning and using insecticide-treated bednets is their cost. Populations affected by malaria are among the poorest in the world and they may not be able to afford insecticide-treated bednets. Wealth, living in an urban rather than rural area, and higher levels of education are other important factors positively associated with insecticide-treated bednet possession and use. Not knowing how to use bednets appropriately can also be a barrier to using them.
| Review objectives: To assess the evidence on the effectiveness and equity of strategies to increase ownership and proper use of insecticide-treated bednets (ITNs). | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Randomised trials, non-randomised trials, controlled before-after studies and interrupted time series studies evaluating interventions to increase ITN ownership and use |
Ten randomised trials: four studies used a combination of strategies focusing on ITN delivery to increase ITN ownership and appropriate ITN use; two studies focused on ITN delivery strategies only; and seven studies examined appropriate use strategies |
| Participants |
Individuals (children and adults) in malaria endemic areas
|
Adults, children under five years, pregnant women, mothers of children under five years, rural cotton farmers |
| Settings | Not specified | Rural communities in Africa, India, and Iran |
| Outcomes | ITN ownership, ITN use and a range of secondary outcomes including (among others) equity ratio of household ITN ownership and adverse effects |
ITN ownership, ITN use, and malaria morbidity |
| Date of most recent search: February 2013 | ||
| Limitations: This was a well-conducted review with only minor limitations | ||
Augustincic Polec L, Petkovic J, Welch V, et al. Strategies to increase the ownership and use of insecticide-treated bednets to prevent malaria. Cochrane Database Syst Rev 2015; 3: CD009186.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
The review included ten studies evaluating interventions to increase insecticide treated bednet possession and use. All the studies were conducted in rural communities in Africa, India and Iran.
Free distribution entails the provision of free insecticide-treated bednets at selected points of care, such as antenatal clinics, and mass campaigns of regional or national provision, usual-ly in tandem with other health interventions.
Distributing insecticide-treated bednets (ITNs) free compared to making ITNs available for purchase |
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| People: Adults (including pregnant women) and children Settings: Rural communities Intervention: Free ITN (with or without social marketing) Comparison: ITN at any cost (with or without social marketing) |
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| Outcomes | Impact | Certainty of the evidence (GRADE) |
|
| ITN possession among pregnant women, adults and children |
Free ITN distribution probably increases the number of pregnant women, adults and children who possess ITNs compared to providing subsidized ITNs or ITNs offered at full market price |
Moderate |
|
| Appropriate use |
Free ITN distribution probably leads to little or no difference in use of ITNs compared to providing subsidized ITNs or ITNs offered at full market price. |
Moderate |
|
| GRADE: GRADE Working Group grades of evidence (see above and last page) | |||
Different educational methods were used (e.g. training for household heads, house to house visits to teach how to properly hang and use insecticide treated bednets, educational bro-chures).
Education about appropriate use of insecticide-treated bednets
Education about appropriate insecticide-treated bednet (ITN) use compared with no education |
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| People: Adults (including pregnant women) and children Settings: Rural communities Intervention: Education about appropriate ITN use Comparison: No education about appropriate ITN use |
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| Outcomes | Impact | Certainty of the evidence (GRADE) |
|
| ITN use by adults (any ITN use) |
Education may increase the number of adults using ITNs (including sleeping under ITNs). |
Low |
|
| ITN use by children under 5 |
Education may increase the number of children under 5 years old using ITNs (including sleeping under ITNs). |
|
|
| GRADE: GRADE Working Group grades of evidence (see above and last page) | |||
An undisclosed prize was promised for appropriate use of insecticide treated bednets to gether with a voucher compared to a bednet voucher and no prize in a study in rural Madagascar.
Providing incentives to encourage the use of insecticide treated bednets
Providing incentives to encourage insecticide-treated bednet (ITN) use compared to no incentives |
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| People: Households Settings: Rural communities Intervention: Providing incentives to encourage ITN use Comparison: Not providing incentives to encourage ITN use |
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| Outcomes | Impact | Certainty of the evidence (GRADE) |
|
| Use (net mounted) |
Providing incentives (a prize) to encourage ITN use may lead to little or no difference in ITN use compared to not providing incentives. |
Low |
|
| GRADE: GRADE Working Group grades of evidence (see above and last page) | |||
| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
| All the included studies were conducted in resource poor settings (rural communities in Africa, India, and Iran). |
The review findings are directly applicable to low income countries.
|
| EQUITY | |
|
Providing free insecticide treated bednets and education improved possession and appropriate use of insecticide treated bednets among vulnerable populations (pregnant women, under five children, low income populations, rural communities).
|
Providing free insecticide-treated bednets and education may reduce health inequities by increasing access and use of insecticide-treated bednets among disadvantaged groups most vulnerable to malaria. |
| ECONOMIC CONSIDERATIONS | |
| Five studies evaluated the effect of insecticide-treated bednet price on possession and found that possession decreased with increasing price. |
Strategies achieving high possession and use of insecticide treated bednets are those which are free or those which deliver insecticide treated bednets at a very low cost. Scaling up such strategies might require substantial subsidies/resource allocation.
|
| MONITORING & EVALUATION | |
|
None of the included studies examined the adverse microeconomic effects of interventions providing free or subsidized insecticide-treated bednets to the community. |
Potential adverse effects of interventions providing free or subsidized insecticide treated bednets should be monitored alongside impacts on clinical outcomes such as malaria related morbidity and mortality.
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm |
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Willey BA, Smith Paintain L, Mangham L, Car J, Armstrong Schellenberg J. Strategies for delivering insecticide-treated nets at scale for malaria control: a systematic review. Bull of the WHO 2012; 90:633-712.
Sexton, AR. Best practices for an insecticide-treated bed net distribution program in sub-Saharan eastern Africa. Malaria Journal 2011; 10:57.
Lengeler C. Insecticide-treated bed nets and curtains for preventing malaria. Cochrane Database Syst Rev 2004; 2:CD000363.
Newton Opiyo, KEMRI-Wellcome Trust Research Programme, Kenya.
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Lana Augustincic Polec, Xavier Bosch-Capblanch, and Paul Garner.
Augustincic Polec L, Petkovic J, Welch V, et al. Strategies to increase the ownership and use of insecticide-treated bednets to prevent malaria. Cochrane Database Syst Rev 2015; 3: CD009186.
Opiyo N. What are the effects of strategies to increase possession and use of insecticide-treated bednets to prevent malaria? A SUPPORT Summary of a sys-tematic review. February 2017. www.supportsummaries.org
evidence-informed health policy, evidence-based, systematic review, health sys-tems research, health care, insecticide-treated bednets, malaria, low and middle-income countries, developing countries,
primary health care
