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Background The burden of malaria in Uganda remains high, but has become increasingly heterogenous following intensified malaria control. Travel within Uganda is recognized as a risk factor for malaria, but behaviours associated with travel are not well-understood. To address this knowledge gap, malaria-relevant behaviours of cohort participants were assessed during travel and at home in Uganda. Methods Residents from 80 randomly selected households in Nagongera sub-county, Tororo district were enrolled into a cohort to study malaria in rural Uganda. All participants were given long-lasting insecticidal nets (LLINs) at enrolment and were evaluated every 4 weeks at the study clinic. Participants were asked if they had travelled overnight from their home, and if so, a questionnaire was administered to capture information on travel details and behaviours. Behaviour while travelling was assessed within 4 weeks following travel during the study clinic visit. Behaviour while at home was assessed using a similar questionnaire during two-weekly home visits. Behaviours while travelling vs at home were compared using log binomial regression models with generalized estimating equations adjusting for repeated measures in the same individual. Analysis of factors associated with LLIN adherence, such as destination and duration of travel, time to bed during travel, gender and age at time of travel, were assessed using log binomial regression models with generalized estimating equations adjusting for repeated measures in the same individual. Results Between October 2017 and October 2019, 527 participants were enrolled and assessed for travel. Of these, 123 (23.2%) reported taking 211 overnight trips; 149 (70.6%) trips were within Tororo. Participants were less likely to use LLINs when travelling than when at home (41.0% vs. 56.2%, relative risk [RR] 0.73, 95% CI 0.60–0.89, p = 0.002); this difference was noted for women (38.8% vs 59.2%, RR 0.66, 95% CI 0.52–0.83, p = 0.001) but not men (48.3% vs 46.6%, RR 0.96, 95% CI 0.67–1.40, p = 0.85). In an adjusted analysis, factors associated with LLIN use when travelling included destination (travelling to districts not receiving indoor residual spraying [IRS] 65.8% vs Tororo district 32.2%, RR 1.80, 95% CI 1.31–2.46, p 7 nights 60.3% vs one night 24.4%, RR 1.97, 95% CI 1.07–3.64, p = 0.03). Conclusions Travellers, particularly women, were less likely to use LLINs when travelling than when at home. LLIN adherence was higher among those who travelled to non-IRS districts and for more than 1 week, suggesting that perceived malaria risk influences LLIN use. Strategies are needed to raise awareness of the importance of using LLINs while travelling.

Background Intensive malaria control may have additional benefits beyond reducing the incidence of symptomatic malaria. We compared antibiotic treatment of children before and after the implementation of highly effective malaria control interventions in Tororo, a historically high transmission area of Uganda. Methods Two successive cohorts of children, aged 0.5 to 10 years, were followed from September 2011 to October 2019 in a dedicated study clinic. Universal distribution of long-lasting insecticidal nets was conducted in 2013 and 2017. Sustained indoor residual spraying of insecticide (IRS) was initiated in December 2014. Generalized linear mixed-effects models were used to compare the incidence of antimalarial and antibiotic treatments before and after vector control measures were implemented. Results Comparing the period prior to the implementation of IRS to the period after IRS had been sustained for 4–5 years, the adjusted incidence of malaria treatments decreased from 2.68 to 0.05 per person-year (incidence rate ratio [IRR] = 0.02, 95% CI 0.01–0.03, p < 0.001), and the adjusted incidence of antibiotic treatments decreased from 4.14 to 1.26 per person-year (IRR = 0.30, 95% CI 0.27–0.34, p < 0.001). The reduction in antibiotic usage was primarily associated with fewer episodes of symptomatic malaria and fewer episodes of fever with sub-microscopic parasitemia, both of which were frequently treated with antibiotics. Conclusions In a historically high transmission setting, the implementation of highly effective vector control interventions was followed by a marked reduction in antibiotic treatment of children. This added benefit of malaria control could have important implications for antibiotic prescribing practices, efforts to curtail antimicrobial resistance, and health system costs.

Research on health systems in resource-limited settings has garnered considerable attention, but the dispensing of individual prescriptions has not been thoroughly explored as a specific bottleneck to effective delivery of care. The rise of human immunodeficiency virus/tuberculosis prevalence and non-communicable diseases in the Kingdom of eSwatini has introduced significant pressures on health facilities to meet patient demands for lifelong medications. Because automated pill counting methods are impracticable and expensive, most prescriptions are made by means of manually counting individual prescriptions using a plastic dish and spatula. The aim of this work was to examine the perceptions of health providers of causes for pill counting errors, and pill counting’s impact on clinic workflow. Our study took place in 13 randomly selected public health facilities in eSwatini, stratified by three groups based on monthly patient volumes. Thirty-one participants who count pills regularly and 13 clinic supervisors were interviewed with semi-structured materials and were audio-recorded for later transcription. Interviews were thematically analysed with inductive coding and three major themes emerged: workflow, counting error causes and effect on clinic function. Findings demonstrate large variety in how facilities manage pill counting for prescription making. Due to patient demands, most facilities utilize all available personnel, from cleaners to nurses, to partake in prescription making. Major causes for pill counting errors were distractions, exhaustion and being hurried. Participants mentioned that patients said that they had initially received the wrong quantity of pills and this affected medication adherence measurements based off pill counts. Most participants described how efforts put into pill counting detracted from their work performance, wasted valuable time and increased patient wait times. Future research is needed to quantify prescription accuracy, but our data suggest that interventions directly alleviating the burden of pill counting could lead to improved clinic quality and possibly improve patient outcomes.

Long-lasting insecticide-treated bednets are widely used and promoted for malaria control. Limitations in measurement methods have resulted in a poor understanding of how bednets are used in practice. We deployed a novel remote monitoring tool in Uganda to obtain, for the first time, a comprehensive characterization of bednet use in households at risk for malaria. Ten households each used one SmartNet adherence monitor over a commonly used sleeping area for 6 weeks. SmartNet continuously measures and records bednet use every 15 minutes. Bednet use was monitored for a total of 9,258 hours overall, with an average of 42 nights per household (SD: 3.5). Average duration of bednet use was 9 hours 49 minutes per night (SD: 1 hour 56 minutes), and adherence was 85-90% from 2100 to 0600. Bednets were not used at all on 4.5% (19/418) of observation nights. Overall, the average clock time that bednets were unfurled was 2034 (SD: 1 hour 25 minutes) and they were folded up at 0743 (SD: 43 minutes). The rate of interruptions per night observed in all households was 0.23 (86/369), with an average duration of 48 minutes (SD: 49 minutes). There was substantial heterogeneity between households, and some households had consistently poorer adherence relative to others. Variations in bednet use behaviors are a potentially important, and under-researched, component of long-lasting insecticide-treated bednet effectiveness. Remote bednet use monitors can provide novel insights into how bednets are used in practice, helping identify both households at risk of malaria due to poor adherence and also potentially novel targets for improving malaria prevention.

Objectives Women may differ by whether they rely on health providers and/or social ties for seeking information and advice about family planning. It is unknown whether these differences matter for contraceptive outcomes. This study assessed the association between women's family planning (FP) network (social and/or provider ties) and contraceptive use. Study Design This cross-sectional, egocentric network study was conducted among reproductive-age women (n = 193) in rural Madagascar. Data included socio-demographics and contraceptive use. Respondents listed who they relied on for contraceptive information, advice or guidance and provided ties’ gender, age, relationship, and perceived support of contraceptive use. The primary outcome was current contraceptive use. Predictors included having a FP network (0/1) and FP network composition (no network, social ties only, provider ties only, both provider and social ties), respectively. Analyses were conducted using a generalized linear model specifying a Poisson distribution, with covariate adjustment and cluster robust standard errors. Results Having a network of individuals to turn to for contraceptive information compared to having no FP network was positively associated with contraceptive use (adjusted relative risk [aRR] 4.4, 95% confidence interval [CI] 2.00–9.87). Having a social network, a provider network, or a combination of social and provider network were all positively associated with contraceptive use (aRR 4.30 [CI 1.92–9.66], aRR 4.46 [CI 2.04–9.75], aRR 4.72 [CI 1.93–11.50], respectively), compared to having no FP network. Conclusions Contraceptive use was higher among women who relied on social ties, provider ties or both for contraceptive information and advice, compared to women with no FP network. These findings suggest that FP interventions should use a multicomponent approach taking into account both social and provider networks. Implications It is unknown whether differences in whether women rely on social ties (friends, partner, family members) vs. providers for contraceptive information and advice affect contraceptive outcomes. Women are just as likely to use contraception whether they rely on social ties, provider ties, or both for contraceptive information and advice.

Introduction Both inpatient and outpatient providers may be at increased risk of stress, anxiety and depression from their roles as health providers during the COVID-19 epidemic. This study explores how the US COVID-19 epidemic has increased feelings of stress, anxiety and depression among outpatient reproductive health providers. Methods We conducted a survey with open-ended responses among outpatient reproductive health providers across the U.S. engaged in contraceptive care to collect data on their experiences with stress, anxiety and depression during the COVID-19 epidemic. The study population included physicians, nurses, social workers, and other health professions [n = 288]. Data were collected from April 21st–June 24th 2020. We used content analysis of free text responses among providers reporting increased stress, anxiety or depression. Results Two-thirds (184) of providers reported increased stress and one-third (96) reported increased anxiety or depression related to care provision during the COVID-19 epidemic. The major sources of stress, anxiety and depression were due to patient care, worry about becoming infected or infecting family members, work- and home-related concerns, experiencing provider burnout, and fear of the unknown. Concerns about quality of patient care, providers’ changing responsibilities, lack of personal protective equipment, and difficulty coping with co-worker illness and absence all contributed to provider stress and anxiety. Worries about unemployment and childcare responsibilities were also highlighted. Providers attributed their stress, anxiety or depression to feeling overwhelmed, being unable to focus, lacking sleep, and worrying about the unknown. Conclusions US outpatient providers are experiencing significant stress, anxiety, and depression during the US COVID-19 epidemic. Policy and programmatic responses are urgently needed to address the widespread adverse mental health consequences of this epidemic on outpatient providers, including reproductive health providers, across the US. Plan English summary Both inpatient and outpatient providers may be at increased risk of stress, anxiety and depression from their roles as health providers during the COVID-19 epidemic. This study explores how the US COVID-19 epidemic has increased feelings of stress, anxiety and depression among outpatient reproductive health providers across the US. We conducted a survey from April 21st to June 24th, 2020 among outpatient reproductive health providers, including physicians, nurses, social workers and other health professions. We asked open-ended questions to understand why providers reported increased stress, anxiety and/or depression. Two-thirds (184) of providers reported increased stress and one-third (96) reported increased anxiety or depression from care provision during the COVID-19 epidemic. Major sources of stress, anxiety and depression were due to patient care, worry about becoming infected or infecting family members, work- and home-related concerns, experiencing provider burnout, and fear of the unknown. Concerns about quality of patient care, providers’ changing responsibilities, lack of personal protective equipment, and difficulty coping with co-worker illness and absence all contributed to provider stress and anxiety. Worries about unemployment and childcare responsibilities were also highlighted. Providers attributed their stress, anxiety or depression to feeling overwhelmed, being unable to focus, lacking sleep, and worrying about the unknown. This study highlights that US outpatient reproductive health providers are experiencing significant stress, anxiety, and depression during the US COVID-19 epidemic. Policy and programmatic responses are urgently needed to address the widespread adverse mental health consequences of this epidemic on outpatient providers, including reproductive health providers, across the US.

Indoor residual spraying (IRS) and long-lasting insecticide-treated bednets (LLINs) are common tools for reducing malaria transmission. We studied a cohort in Uganda with universal access to LLINs after 5 years of sustained IRS to explore LLIN adherence when malaria transmission has been greatly reduced. Eighty households and 526 individuals in Nagongera, Uganda were followed from October 2017 –October 2019. Every two weeks, mosquitoes were collected from sleeping rooms and LLIN adherence the prior night assessed. Episodes of malaria were diagnosed using passive surveillance. Risk factors for LLIN non-adherence were evaluated using multi-level mixed logistic regression. An age-matched case-control design was used to measure the association between LLIN non-adherence and malaria. Across all time periods, and particularly in the last 6 months, non-adherence was higher among both children

Insecticide-treated bednets are among the most prevalent and cost-effective tools for preventing malaria throughout the world. Consistent bednet use is crucial for effectiveness, but assessing adherence is challenging due to limitations in current measurement tools. Recent technologies have introduced methods for remote electronic bednet use monitoring. While valuable for researchers, these monitoring tools create potential ethical concerns for study bystanders because the monitors are typically unable to discriminate between individuals who are or are not study participants. Considerations related to study bystanders, including privacy, ancillary care obligations, and community perceptions, are discussed.

Background Insecticide-treated bednets (ITNs) are recommended for use by 3.4 billion people at risk of malaria world-wide. Policy makers rely on measurements of ITN use to optimize malaria prevention efforts. Self-reports are the most common means of assessing ITN use, but self-reports may be biased in a way that reduces their reliability as a proxy for ITN adherence. This meta-analysis compared self-reported and two methods which are more objective measures of ITN use to explore whether self-reports overestimate actual ITN adherence. Methods A comprehensive search of electronic databases and hand searching reference lists resulted in screening 2885 records and 202 articles were read in full. Sixteen articles with comparable data were chosen for the meta-analysis. Comparable data was defined as self-reported and objectively measured ITN use (observation of a mounted ITN or surprise visits confirming use) at the same unit of analysis, covering the same time period and same population. A random effects model was used to determine a weighted average risk difference between self-reported and objectively measured ITN use. Additional stratified analyses were conducted to explore study heterogeneity. Results Self-reported ITN use is 8 percentage points (95% confidence interval CI: 3 to 13) higher than objectively measured ITN use, representing a 13.6% overestimation relative to the proportion measured as adherent to ITN use by objective measures. Wide variations in the discrepancies between self-reports and objective measures were unable to be explained using stratified analyses of variables including location, year of publication, seasonality and others. Conclusions Self-reports overestimate ITN adherence relative to objectively measured ITN use by 13.6% and do so in an unpredictable manner that raises questions about the reliability of using self-reported ITN use alone as a surveillance tool and a guide for making policy decisions.

Insecticide-treated bednets (ITNs) are a mainstay of malaria prevention, yet poor adherence poses a major barrier to effective prevention. Self-reports of bednet use suffer from recall and social desirability biases. We have designed a device that electronically records ITN usage longitudinally. SmartNet consists of circuits made from a conductive fabric interwoven into the sides and top of a rectangular ITN. Digital sampling of the state of these circuits allows for determining whether the SmartNet is deployed for use or folded up. We conducted a study among pregnant women and women with children

Malaria is a leading cause of mortality and morbidity in sub–Saharan Africa, accounting for over one million deaths each year and 600 000–800 000 deaths among children less than five years of age [1,2]. Malaria is a significant health problem in Madagascar, representing a significant burden for the health system. Malaria–related illness makes up 16% of all outpatient visits and is the leading cause of child mortality, killing nearly 20 000 children under five years of age every year [3]. Insecticide–treated bednets (ITNs) are one of the most effective tools for preventing malaria [4,5]. ITNs are estimated to be as cost–effective as the measles vaccination [6] and ITN ownership is associated with an 18%–23% decrease in child mortality in sub–Saharan African households [7]. According to the World Health Organization (WHO), large–scale distribution programs in sub–Saharan Africa have improved access to ITNs in recent years, with the percentage of households owning at least one ITN rising from an average of 3% in 2000 to 53% in 2012 [8]. Nevertheless, ITN coverage continues to lag behind the Roll Back Malaria Partnership goal of 80% ITN coverage of under five-year-old children by 2010. Indeed, in Madagascar, only 46% percent of children under five were sleeping under ITNs based on 2006–2010 estimates [9]. Understanding what factors predict household ownership and use of nets is important for improving policies and programs to increase ITN coverage. Most recent studies of the predictors of bednet ownership and use have taken place in the setting of large distribution campaigns. Fewer studies have looked at the predictors of bednet ownership and use outside of subsidized distribution programs or outside of controlled trials [10–13]. This is of particular interest because households that do not contain members who are targeted for subsidized distribution programs, such as children under 5 years or pregnant women, continue to encounter a relatively scarce supply of quality and affordable ITNs [14,15]. We undertook this study in order to identify household–level factors that are associated with bednet ownership in a rural area of Madagascar. We were interested in why some households seek out bednets even when they are not provided for free or as part of large–scale programs. We also investigated predictors of high levels of malaria knowledge to further our understanding of the generic origins of household demand for ITNs.

Background: Malaria infections are the leading cause of death for children in Madagascar. Insecticide-treated bednets offer effective prevention but it is unclear how well free bednet distribution programs reach young children. Methods: We conducted a secondary analysis of a free bednet distribution program in Madagascar from 2007-2008. Interviews were performed at baseline and 6 months. Principal components analysis was used to construct a wealth and malaria knowledge index. Coverage efficiency was calculated as coverage of children per bednet owned. Univariable and multivariable regressions were used to determine predictors of bednet use. Results: Bednet use among the 560 households in the study increased from 6 to 91% after 6 months. Coverage efficiency increased from 1.29 to 1.56 children covered per bednet owned. In multivariable analysis having a child under 5 years of age was the only variable associated with bednet use (OR 9.10; p=0.001) yielding a 99% likelihood of using a bednet (95% CI 96.4 to 99.9%) versus 82% (95% CI 72.2 to 88.4%) in households without young children. Conclusion: This free bednet distribution program achieved high levels of adherence after 6 months. Household presence of children was associated with bednet use but not household income or education suggesting that distribution to priority groups may help overcome traditional barriers to adoption in some settings.

Malaria is a serious health concern for three billion people worldwide, killing nearly 600,000 people a year. Insecticide-treated bednets (ITNs) are an effective and valuable tool for preventing malaria and hundreds of millions of ITNs have been distributed throughout sub-Saharan Africa. Nevertheless, our current methods for measuring ITN use are inadequate to inform malaria prevention programs. The most common method, self-reported ITN use, is limited by 1) social desirability, 2) recall and 3) sampling bias. An acceptable objective and longitudinal method of assessing adherence to ITN use would improve our ability to better understand the determinants of ITN use and design more effective malaria prevention interventions. We describe the development and initial proof-of-concept validity testing of an ITN adherence monitoring tool called SmartNet. SmartNet uses conductive thread interwoven into an ITN and a microcontroller to detect the state of the ITN. We tested SmartNet among five volunteers using the device over their beds in Boston, USA for two weeks with the goal of evaluating device reliability, accuracy and acceptability to inform future device improvements. The device recorded data for 63.1% (35172/55711) of installed two-minute time intervals, with 97.3% (19990/20539) of the recording errors relating to battery failures. Overall, the device was 71.7% (25204/35172) accurate in determining the state of the ITN (whether it was folded up or unfurled) and performed significantly better at detecting an unfurled ITN than a folded ITN, 77.3% versus 68.4% (p

Background Insecticide-treated bed nets (ITNs) have been shown to reduce morbidity and mortality due to malaria in sub-Saharan Africa. Strategies using incentives to increase ITN use could be more efficient than traditional distribution campaigns. To date, behavioural incentives have been studied mostly in developed countries. No study has yet looked at the effect of incentives on the use of ITNs. Reported here are the results of a cluster randomized controlled trial testing household-level incentives for ITN use following a free ITN distribution campaign in Madagascar. Methods The study took place from July 2007 until February 2008. Twenty-one villages were randomized to either intervention or control clusters. Households in both clusters received a coupon redeemable for one ITN. After one month, intervention households received a bonus for ITN use, determined by visual confirmation of a mounted ITN. Data were collected at baseline, one month and six months. Both unadjusted and adjusted results, using cluster specific methods, are presented. Results At baseline, 8.5% of households owned an ITN and 6% were observed to have a net mounted over a bed in the household. At one month, there were no differences in ownership between the intervention and control groups (99.5% vs. 99.4%), but net use was substantially higher in the intervention group (99% vs. 78%), with an adjusted risk ratio of 1.24 (95% CI: 1.10 to 1.40; p < 0.001). After six months, net ownership had decreased in the intervention compared to the control group (96.7% vs. 99.7%), with an adjusted risk ratio of 0.97 (p < 0.01). There was no difference between the groups in terms of ITN use at six months; however, intervention households were more likely to use a net that they owned (96% vs. 90%; p < 0.001). Conclusions Household-level incentives have the potential to significantly increase the use of ITNs in target households in the immediate-term, but, over time, the use of ITNs is similar to households that did not receive incentives. Providing incentives for behaviour change is a promising tool that can complement traditional ITN distribution programmes and improve the effectiveness of ITN programmes in protecting vulnerable populations, especially in the short-term.