Factors associated with the use of mosquito bed nets: results from two cross-sectional household surveys in Zambézia Province, Mozambique

According to the World Health Organization, 214 million cases of malaria occurred in 2015, resulting in 438,000 deaths. Eighty-eight percent of these deaths occurred in the Africa region. Malaria is one of the two leading causes of death in Mozambique, accounting for 29% of all deaths in 2008. In 2011, malaria was reported as the leading cause of death in children under 5 years. Malaria is considered endemic throughout Mozambique, with transmission occurring year-round but with seasonal peaks during and directly after the rainy season, typically from December to April. Regional prevalence of malaria can be quite different across the country, ranging from 1.5% in Maputo in the south to 54.8% in Zambézia Province in the north in 2011. Additionally, a threefold higher prevalence has been reported in rural areas compared to urban. Mozambique's National Malaria Control Programme is responsible for developing policy, planning, and coordinating all malaria control activities within the country. In recent years, major investments have been made through programs such as the United States President's Malaria Initiative (PMI) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund). Mozambique's National Malaria Prevention and Control Strategic Plan: 2012-2016 continues to focus heavily on four proven and highly effective prevention and treatment strategies: insecticide-treated mosquito nets (ITNs), indoor residual spraying (IRS), diagnosis and treatment with artemisinin-based combination therapy (ACT), and intermittent preventive treatment of pregnant women (IPTp). For several years, a cornerstone of Mozambique's vector control strategy has been to strive for universal coverage of ITNs. Coverage and mosquito net usage have been slowly increasing amongst key target groups. Nationwide, from 2007 to 2015, the proportion of children under 5 years of age using an ITN in the previous night increased from 7 to 36%. Surveillance surveys conducted as part of the Malaria Decision Support System Project in Zambézia Province, a high malaria prevalence region, reported an increase of ITN usage in children under 5 years from 29.8% in 2006 to 34.3% in 2009. Despite these reported increases, the country has not yet been able to report a consistent and sustained decline in malaria incidence. Current ITN distribution strategies prioritize extremely vulnerable populations and strive for 80% coverage of young children and pregnant women. Evidence shows that further protective effects can be gained when sufficient portions of all individuals at risk consistently utilize mosquito nets. The Ogumaniha project began implementation in Zambézia Province, Mozambique in late 2009. The project is funded by the US Government under the United States Agency for International Development (USAID) Strengthening Communities through Integrated Programming (SCIP) award and implemented by a consortium of partners led by World Vision. The overarching goal of this 5-year project is to improve the health and livelihoods of women, children, and families in Zambézia Province by pursuing an integrated, innovative, and sustainable community-based program supporting cross-sector integration of USAID's development actions in the province. In order to achieve the above objectives, the Ogumaniha consortium structured its interventions through a mixture of training and capacity building of local community volunteer groups called community health committees (CHCs), as well as direct implementation of activities by consortium partners. CHCs are networks of volunteers within a community usually consisting of 20-30 volunteers. These volunteers are then divided into thematic areas of community support such as nutrition; maternal health/family planning/reproductive health; home-based care; water and sanitation; home visits and active case finding for persons living with HIV; child health; local economic development; and malaria education and prevention. Ogumaniha's malaria-related activities primarily focused on community-based education messages and behavior change communications promoting improved health-seeking behavior, as well as the active identification and referral of suspected malaria cases in the community to a health facility for testing and treatment. In addition, the Ogumaniha consortium assisted provincial supply chain systems for the monthly transport of ITNs to the province's 200+ health facilities in order to stock programs supporting universal distribution within antenatal care clinics.