Open Access

Progress in coverage of bed net ownership and use in Burkina Faso 2003–2014: evidence from population-based surveys

  • Sekou Samadoulougou1Email author,
  • Morgan Pearcy2,
  • Yazoumé Yé3 and
  • Fati Kirakoya-Samadoulougou4, 5
Malaria Journal201716:302

https://doi.org/10.1186/s12936-017-1946-1

Received: 25 April 2017

Accepted: 18 July 2017

Published: 28 July 2017

Abstract

Background

Use of insecticide-treated bed nets (ITNs) is the cornerstone of malaria prevention. In 2010 and 2013, the Burkina Faso Government launched mass distribution campaigns of ITNs to increase coverage of ownership and use in the country. This study assessed the progress towards universal bed net coverage in Burkina Faso.

Methods

The authors used data from the Burkina Faso 2003 and 2010 Demographic and Health Surveys (DHS), the 2006 Multiple Indicator Cluster Surveys (MICS) and the 2014 Malaria Indicator Survey (MIS). For each survey, the authors computed key malaria prevention indicators in line with recommendations from the Survey and Indicator Task Force of the Roll Back Malaria Monitoring and Evaluation Reference Group. The trends over a decade was assessed by calculating percentage point change between 2003 and 2014.

Results

At national level, the proportion of households owning at least one ITN increased substantially 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 at least one ITN per two people increased significantly from 1.8% (1.4, 2.3%) in 2003 to 49.2% (47.3, 51.0%) in 2014. ITN use in the general population increased from 2.0% (1.6, 2.3%) in 2003, to 67.0% (65.3, 68.7%) in 2014. A similar trend was observed among children under the age of  five years, increasing from 1.9% (1.5, 2.4%) in 2003 to 75.2% (73.2, 77.3%) in 2014, and among pregnant women, increasing from 3.0% (1.9, 4.2%) in 2003 to 77.1% (72.9, 81.3%) in 2014. The intra-household ownership gap was 67.0% (61.5, 72.4%) in 2003, but decreased significantly to 45.3% (43.6, 47.1%) in 2014. The behavioural gap, which was relatively low in 2013 with only 20.0% of people who had access to an ITN but were not using it, further decreased to 5.9% in 2014.

Conclusion

Burkina Faso made considerable progress in coverage of ITN ownership, access and use between 2003 and 2014, as a result of the two free mass distribution campaigns in 2010 and 2013. However, ITN coverage remains below the national targets of 100% for ownership and 80% for use. The results of 90% of ownership and 67% of use confirm that free mass distribution campaigns of ITNs are effective; however, there is room for improvement to reach and maintain optimal coverage of ITN ownership and use.

Keywords

Bed net LLIN ownership gap LLIN use gap LLIN access gap Behavioural failure Malaria

Background

Insecticide-treated bed nets (ITNs) are effective tools for malaria control [1]. Meta-analyses have shown that ITNs are associated with an 18% reduction in child mortality [2], 51% decrease in uncomplicated malaria incidence and 17% reduction in parasite prevalence in children [3]. In the past decade, the rapid scale-up of bed nets in sub-Saharan Africa (SSA) contributed to the significant decline of malaria burden in the region [4, 5]. Sustaining high coverage of this intervention is critical to decrease further the burden of the disease and reach the long term-goal of malaria elimination. It is estimated that a minimum of 150 million ITNs per year are needed to maintain a constant pool of 450 million functioning ITNs to protect individuals at risk in SSA [6].

Increasing ITN coverage has been achieved using various distribution strategies, including social marketing [79], free distribution to target vulnerable groups (pregnant women and children under the age of five) through antenatal care (ANC) or immunization campaigns [7, 8, 1012], and more recently, free, universal, population-based distribution campaigns targeting the general population [7, 8, 10, 1218]. The World Health Organization (WHO) recommends to distribute free or subsidize bed nets as the best way to ensure full coverage [19].

In 2001, a nationwide survey in Burkina Faso estimated that only 12.4% of children under the age of five were sleeping under a net, compared to 23.2% in 2005. Among pregnant women this proportion was 10.0% in 2001 and 27.5% in 2005 [20]. To rapidly increase coverage of ITN ownership and use, particularly among vulnerable groups, the Government of Burkina Faso initiated a first national-scale, free distribution campaign of ITNs in 2010. The aim of the campaign was to ensure that households had access to at least one ITN for every two people through the distribution of about eight million long-lasting insecticidal nets (LLINs). Moreover, in 2013, the national malaria control programme (NMCP) launched the second free LLIN distribution campaign to scale-up the coverage of ITNs in the country. This campaign aimed to ensure that 100% of households owned at least one ITN, and reach 80% ITN use by 2015. In 2014, the Burkina Faso Government decided to conduct the first Malaria Indicator Surveys (MISs) to assess coverage and impact of scaled-up malaria interventions. MISs were developed by the Roll Back Malaria (RBM) Monitoring and Evaluation Reference Group (MERG) with the aim to help national ministries of health collect key and timely information on malaria control at national level [21]. As Burkina Faso aims to achieve universal coverage with LLINs, this paper assessed the progress and gaps in coverage of bed net ownership and use based on RBM/MERG-recommended indicators [21].

Methods

The authors analysed regional trends of ITNs ownership, access and use indicators in Burkina Faso over 11 years. These indicators were computed using data from the 2003 and 2010 Demographic and Health Surveys (DHS) [22, 23], 2006 Multiple Indicators Cluster Survey (MICS) [24] and the first national MIS 2014 [25]. At the time of these surveys, Burkina Faso was divided into 13 administrative regions.

Data from Demographic and Health Survey 2003 and 2010

DHS 2003 (between June and December 2003) and DHS 2010 (between May 2010 and January 2011) were conducted during the high transmission season. DHS was designed to obtain national and regional estimates for malaria indicators. The DHS surveys followed a two-stage selection process in which a random sample of clusters was first selected from the most recent national sample frame. In the second stage, all households were listed and the final list of households selected by systematic random sample. In the Burkina Faso DHS, the sample was selected in two stages, stratified by place of residence (urban and rural) with enumeration areas (EAs) as the first-stage sampling units, and households as the second-stage sampling units. Further details are provided in the DHS reports [22, 23].

Data from MIS 2014

The MIS data were collected from October to November 2014 (at the end of the high transmission season), using the standard malaria indicator questionnaires developed by the RBM and the DHS Program. The dataset consists of malariometric information, demographic characteristics and socio-economic status on a nationally representative sample of 6448 households from 252 clusters, of which 52 are in the urban areas. These clusters were derived from a stratified two-stage cluster design. A detailed description of the sampling strategies is documented in the final report of the 2014 Burkina Faso MIS [25].

Data from MICS 2006

Multiple Indicator Cluster Surveys are typically carried out by government organizations with the support and assistance of UNICEF to fill data gaps for monitoring the children and women wellbeing. The Burkina Faso MICS conducted from March to June 2006 used a two-stage stratified sample design. At the first stage of sampling, 198 census EAs (197 visited) were selected. The clusters in each region were selected using systematic sampling with probability proportional to their size. A complete household-listing exercise covering all EAs in the 2003 Burkina Faso DHS was carried out. At the second stage, a systematic sampling of households was selected based on this list. For the 2006 Burkina Faso MICS, 30 households per EA were selected per rural EA, 32 (in Ouagadougou, the capital city) to 36 households per urban EA. Due to the fixed sample size per EA, the disproportional number of EAs and different sample sizes selected per EA among regions, the household sample is not self-weighting at the national level. A more detailed description of the sample design can be found elsewhere [24].

Indicators

Ownership, access, use, and gap indicators were calculated from the datasets of households and individual household members, as recommended by MERG [21] (Table 1).
Table 1

RBM/MERG-approved indicators used

Indicator

Numerator

Denominator

Ownership

 Proportion of households in the survey with at least one ITN (P1)

Number of households owning at least one ITN

Number of households in the survey

 Proportion of households with sufficient access to ITN (P2)

Number of households owning at least one ITN for every two household members

Number of households in the survey

 Proportion of population with access to ITN within the household (P3)

Potential number of household members protected by the ITN (i.e., number of ITN owned multiplied by two), or number of de facto household members in the household, whichever was the lowest

Population in the survey

 Proportion of households with at least one ITN for every two people among households owning any ITN (P7)

Number of households owning at least one ITN for every two household members

Number of households owning at least one ITN

Intra-ownership gap, the proportion of households owning less than one ITN for every two household members, is calculated as 1-P7

Use

 Proportion of population sleeping under an ITN the previous night (P4)

Number of household members who slept under an ITN the night before the survey

Population in the survey

 Proportion of children under 5 years sleeping under an ITN the previous night (P5)

Number of children under 5 years who slept under an ITN the night before the survey

Number of children under five years in surveyed households

 Proportion of pregnant women sleeping under an ITN the previous night (P6)

Number of pregnant women who slept under an ITN the night before the survey

Number of pregnant women in surveyed households

 Proportion of population sleeping under an ITN the previous night among those with access (P8)

Number of household members who slept under an ITN the night before the survey

Total number of people with access to an ITN, calculated as the sum of all access (P3) values

Behavioural gap, the proportion of household members who did not sleep under an ITN despite having access to one, is calculated as 1-P8

Statistical methods

Data was analysed using Stata version 14 software and the maps were made using the R software. Point estimates (in percentage) and 95% confidence intervals were computed for each indicator and data point. In addition the percentage point changes between the baseline (2003) and endline (2014) were computed to assess change in the indicator and statistical significance assess at 5% level. Change by region and socio-demographical factor of each indicator between 2003 and 2014 were explored using the difference between weighted proportions (with svy prop command for survey data analysis) in Stata version 14 followed by a Lincom command (Linear combination of estimators). The survey mean command followed by Lincom (to compute two-sample t-test for difference in means with sampling weights) was used for the continuous variable access. Using this approach, we were directly testing whether the observed difference was significantly superior to zero.

Results

ITN ownership at household level (referred to as percentage 1-P1)

Respectively, 9097, 6034, 14,424, and 6448 households were visited in the DHS 2003, MICS 2006, DHS 2010, and MIS 2014. Ownership of ITN at household level in Burkina Faso was 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, compared to 89.9% (88.5, 91.2%) in 2014 (Fig. 1). Overall ownership of ITNs at household level increased significantly from 2003 to 2014 (p < 0.001, Fig. 1). Ownership of ITNs in rural areas increased from 3.2% in 2003 to 90.8% in 2014 (p < 0.001). In urban areas, a percentage point increase of 72.5 of ITN ownership by households was observed from 2003 to 2014 (p < 0.001). In 2003, the richest households had the highest level of ITN ownership (15.8 vs 1.8% for poorest households). In 2014, ITN ownership increased and reached 84.4% in the poorest quintile compared to 87.4% in the richest quintile (Table 2).
Fig. 1

Trends of main malaria prevention indicators between 2003 and 2014, Burkina Faso. Panel A (ITN ownership) represents the proportion of households owning at least 1 ITN, owning 1 ITN for 2 household members and the proportion of individuals with access to an IT. Panel B (ITN use) represents the proportion of people who slept under an ITN the night before the survey for the whole population, among children under five years old and among pregnant women. Panel C (gap indicators) represents the proportion of household onwing at least 1 ITN, but less than 1 for every 2 household members (intraownership gap), and the proportion of people having access to an ITN but who did not use it the night before the survey (behavioural gap). All indicators are plotted for the 2003, 2006, 2010 and 2014 surveys, along with their 95% confidence interval

Table 2

Proportion of households owning at least one insecticide-treated bed net

Background characteristic

DHS 2003

MICS 2006

DHS 2010

MIS 2014

Percentage point change (2003–2014)

% (95% CI)

N

% (95% CI)

N

% (95% CI)

N

% (95% CI)

N

Residence

 Urban

14.8 (12.5–17.2)

2182

45.0 (38.6–51.4)

921

60.0 (56.9–63.0)

4391

87.8 (85.2–90.4)

1305

72.5 (69.0–76.0)

 Rural

3.2 (2.4–4.0)

6868

14.9 (12.8–17.1)

4602

55.9 (53.3–58.5)

9997

90.8 (89.2–92.4)

5104

87.6 (85.8–89.4)

Household wealth quintiles

 Poorest

1.8 (0.7–3.0)

1880

8.4 (6.4–10.5)

1276

48.8 (44.9–52.7)

2620

84.4 (81.0–87.7)

1511

82.6 (79.0–86.2)

 Poorer

2.6 (1.6–3.7)

1619

13.3 (10.5–16.1)

1276

53.4 (50.2–56.7)

2744

91.8 (90.2–93.4)

1385

89.0 (87.2–90.9)

 Average

2.8 (1.8–3.8)

2023

14.1 (10.7–17.4)

1116

56.8 (53.7–60.0)

2777

93.8 (92.2–95.4)

1288

91.1 (89.2–92.9)

 Richer

3.8 (2.4–5.2)

1407

23.5 (18.9–28.1)

1013

59.5 (56.4–62.7)

2922

94.0 (91.5–96.4)

1236

90.1 (87.3–92.8)

 Richest

15.8 (13.3–18.3)

2121

52.1 (45.7–58.4)

842

65.1 (62.3–67.9)

3325

87.4 (84.9–89.9)

989

70.8 (67.1–74.4)

Size of the household

 Small (1–5 members)

6.0 (4.7–7.2)

4421

24.5 (19.4–29.7)

2345

53.3 (51.1–55.6)

8169

88.3 (86.6–90.0)

3362

82.0 (79.8–84.1)

 Medium (6–8 members)

5.5 (4.1–6.8)

2401

22.7 (18.9–26.5)

1665

60.3 (57.8–62.8)

3911

91.4 (89.6–93.2)

1760

85.9 (83.6–88.2)

 Lager (9+ members)

4.8 (3.7–5.9)

2228

21.9 (17.4–26.3)

1513

63.7 (60.8–66.7)

2308

92.6 (90.8–94.5)

1287

87.8 (85.7–89.9)

All estimates take into account sample weights

CI Confidence intervals, DHS Demographic and Health Survey, MICS Multiple Clusters Indicator Survey, MIS Malaria indicator Survey, N number of households

Insecticide-treated bed nets coverage also increased significantly in different regions from 2003 to 2014. The percentage point increases were consistently high across regions (from 76.9 to 94.5). Compared to 2003 and 2010, ITN ownership was rather stable across the country and displayed limited geographic heterogeneity in 2014 (Fig. 2).
Fig. 2

Trends of main ownership indicators between 2003 and 2014, Burkina Faso. The proportion of households owning at least 1 ITN (a), owning at least 1 ITN for 2 household members (b) and the proportion of the population with access to an ITN (c) is indicated for each region, for 2003, 2006, 2010, and 2014, respectively

ITN ownership at household level (P2: households with at least one ITN for every two people)

The proportion of households with enough ITNs for every household member, i.e., at least one ITN for every two people, was 1.8% (1.4, 2.3%) in 2003, 8.4% (6.1, 11.4%) in 2006, 18.5% (17.1, 20.0%) in 2010, compared to 49.2% (47.3, 51.0%) in 2014, indicating a substantial increase (p < 0.001). Household access to ITNs improved significantly from 2003 to 2014 in urban and rural areas, in all quintiles of wealth and in the different regions in Burkina Faso. The largest increases were observed in urban areas amongst the richest two quintiles, in smallest households and in the Hauts-Bassins and Central-South regions (Table 3). In these two regions, 62.5 and 60.4% households, respectively, owned at least one ITN for every two members in 2014 (Fig. 2).
Table 3

Proportion of households owning at least one insecticide-treated bed net for every two members

Background characteristic

DHS 2003

MICS 2006

DHS 2010

MIS 2014

Percentage point change (2003–2014)

% (95% CI)

N

% (95% CI)

N

% (95% CI)

N

% (95% CI)

N

Residence

 Urban

5.8 (4.2–7.4)

2182

20.9 (16.2–25.7)

921

24.8 (22.5–27.1)

4391

55.6 (52.4–58.8)

1305

49.0 (45.4–52.6)

 Rural

0.8 (0.5–1.1)

6868

3.6 (2.7–4.4)

4602

16.4 (14.6–18.1)

9997

46.5 (44.4–48.5)

5104

45.4 (43.3–47.5)

Household wealth quintile

 Poorest

0.6 (0.1–1.1)

1880

1.5 (0.8–2.2)

1276

12.4 (10.3–14.5)

2620

41.1 (37.0–45.1)

1511

40.3 (36.3–44.4)

 Poorer

0.2 (0.0–0.5)

1619

2.4 (1.3–3.4)

1276

15.4 (13.2–17.7)

2744

47.4 (44.2–50.7)

1385

47.0 (43.8–50.2)

 Average

0.5 (0.2–0.9)

2023

3.7 (2.3–5.0)

1116

17.0 (14.7–19.2)

2777

45.6 (42.3–48.8)

1288

44.8 (41.5–48.1)

 Richer

0.8 (0.3–1.3)

1407

5.3 (3.5–7.0)

1013

17.7 (15.4–20.0)

2922

52.2 (48.7–55.6)

1236

51.0 (47.6–54.5)

 Richest

6.5 (4.8–8.1)

2121

25.8 (21.0–30.6)

842

28.6 (26.2–31.0)

3325

58.3 (55.0–61.6)

989

50.9 (47.2–54.5)

Size of the household

 Small (1–5 members)

3.3 (2.5–4.0)

4421

14.4 (10.2–18.6)

2345

26.7 (24.7–28.7)

8169

65.7 (63.6–67.9)

3362

61.5 (59.3–63.8)

 Medium (6–8 members)

0.7 (0.1–1.2)

2401

5.3 (3.6–7.0)

1665

9.8 (8.5–11.2)

3911

37.2 (34.1–40.2)

1760

36.5 (33.3–39.7)

 Large (9+ members)

0.1 (0.0–0.3)

2228

1.2 (0.6–1.7)

1513

4.2 (3.1–5.3)

2308

17.9 (15.3–20.4)

1287

17.8 (15.2–20.3)

All estimates take into account sample weights

CI Confidence intervals, DHS Demographic and Health Survey, MICS Multiple Clusters Indicator Survey, MIS Malaria indicator Survey; N number of households

Access to ITN at population level (P3)

Access to ITNs increased significantly 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, and reached 71.2% (69.6, 72.8%) in 2014 (p < 0.001) (Table 4; Fig. 1).
Table 4

Proportion of population having access to an insecticide-treated bed net

Background characteristic

DHS 2003

MICS 2006

DHS 2010

MIS 2014

Percentage point change (2003–2014)

% (95% CI)

N

% (95% CI)

N

% (95% CI)

N

% (95% CI)

N

Residence

 Urban

8.1 (6.6–9.6)

12,313

28.8 (23.4–34.1)

5691

40.2 37.3–43.0)

21,758

71.1 (6 7.8–74.4)

6733

63.0 (59.4–66.7)

 Rural

1.3 (0.9–1.7)

46,530

8.5 (7.1–9.9)

32,813

34.9 (32.6–37.2)

58,774

71.2 (69.4–73.0)

31,660

69.9 (68.0–71.8)

Household wealth quintiles

 Poorest

0.7 (0.3–1.2)

10,802

4.3 (3.1–5.5)

8734

29.5 (26.4–32.6)

15,243

63.0 (59.7–66.4)

8380

62.3 (58.9–65.7)

 Poorer

0.9 (0.5–1.2)

11,113

7.8 (5.8–9.7)

8072

33.5 (30.8–36.3)

15,389

72.3 (70.2–74.3)

8495

71.4 (69.3–73.5)

 Average

1.1 (0.4–1.8)

14,345

8.2 (6.2–10.3)

8685

35.8 (33.0–38.5)

16,306

74.0 (72.0–76.0)

8520

72.8 (70.7–75.0)

 Richer

1.5 (0.8–2.2)

10,056

12.0 (9.2–14.8)

7702

37.5 (34.8–40.2)

16,989

74.8 (72.4–77.3)

8165

73.3 (70.7–75.9)

 Richest

8.3 (6.8–9.7)

12,527

34.9 (29.5–40.2)

5311

44.1 (41.4–46.7)

16,605

71.8 (68.1–75.6)

4833

63.5 (59.5–67.6)

Size of the household

 Small (1–5 members)

4.2 (3.2–5.1)

14,278

19.1 (15.0–23.2)

8166

42.2 (40.0–44.4)

27,130

79.7 (77.9–81.4)

11,250

75.5 (73.5–77.5)

 Medium (6–8 members)

2.7 (1.9–3.5)

16,500

14.1 (11.4–16.7)

11,415

36.2 (34.0–38.3)

26,634

73.1 (71.0–75.2)

12,025

70.4 (68.1–72.7)

 Large (9+ members)

1.5 (1.0–1.9)

28,065

10.2 (7.9–12.5)

19,434

29.8 (27.6–32.1)

26,768

62.7 (60.4–64.9)

15,118

61.2 (58.9–63.5)

All estimates take into account sample weights

CI Confidence intervals, DHS Demographic and Health Survey, MICS Multiple Clusters Indicator Survey, MIS Malaria indicator Survey, N number of individuals

Use of ITN at individual level (P4)

In 2003, 2.0% (1.6, 2.3%) slept under a net. In 2010, the proportion of people who slept under an ITN was 31.5% (29.8, 33.2%) compared to 67.0% (65.3, 68.7%) in 2014, suggesting a considerable increase of 65.0% points from 2003 to 2014 (p < 0.001, Fig. 1). In urban areas, 5.6% of individuals used ITNs in 2003, a proportion that increased to 61.8% by 2014 (p < 0.001). In rural areas, a significant increase was also observed, with 1.2% of people who used an ITN in 2003 and 68.8% in 2014 (p < 0.001). The substantial increase in the proportion of people who slept under ITNs was observed across all quintiles of wealth. Use of ITNs increased significantly from 0.8% in 2003 to 63.7% in 2014 (p < 0.001) in the poorest wealth quintile. In the second poorest wealth quintile, ITN use increased from 0.8% in 2003 to 69.1% in 2014 (p < 0.001), compared to an increase of 54.9% points in the richest quintile (6.1–61.0%) (Table 5).
Table 5

Proportion of population who slept under an insecticide-treated bed net the night before the survey

Background characteristic

DHS 2003

MICS 2006a

DHS 2010

MIS 2014

Percentage point change (2003–2014)

% (95% CI)

N

% (95% CI)

N

% (95% CI)

N

% (95% CI)

N

Residence

 Urban

5.6 (4.4–6.7)

12,313

31.2 (28.0–34.5)

21,758

61.8 (58.8–64.8)

6733

56.2 (53.0–59.4)

 Rural

1.2 (0.8–1.5)

46,530

31.6 (29.5–33.6)

58,774

68.8 (67.0–70.6)

31,660

67.6 (65.8–69.5)

Household wealth quintiles

 Poorest

0.8 (0.3–1.2)

10,802

25.9 (23.4–28.5)

15,243

63.7 (60.5–66.8)

8380

62.9 (59.7–66.1)

 Poorer

0.8 (0.4–1.1)

11,113

30.2 (27.7–32.7)

15,389

69.1 (66.9–71.3)

8495

68.3 (66.1–70.5)

 Average

0.9 (0.4–1.5)

14,345

32.7 (30.2–35.1)

16,306

71.2 (68.8–73.5)

8520

70.2 (67.8–72.7)

 Richer

1.3 (0.7–1.9)

10,056

34.5 (31.8–37.1)

16,989

70.1 (67.6–72.6)

8165

68.8 (66.2–71.4)

 Richest

6.1 (4.8–7.3)

12,527

34.2 (31.1–37.3)

16,605

61.0 (57.8–64.2)

4833

54.9 (51.5–58.3)

Size of the household

 Small (1–5 members)

3.1 (2.5–3.8)

14,278

37.3 (35.2–39.3)

27,130

72.3 (70.3–74.4)

11,250

69.2 (67.0–71.3)

 Medium (6–8 members)

2.1 (1.4–2.8)

16,500

31.0 (29.0–33.0)

26,634

69.5 (67.4–71.6)

12,025

67.4 (65.2–69.7)

 Large (9+ members)

1.2 (0.8–1.7)

28,065

26.2 (24.1–28.4)

26,768

60.6 (58.1–63.0)

15,118

59.4 (56.8–61.9)

All estimates take into account sample weights

CI Confidence intervals, DHS Demographic and Health Survey, MICS Multiple Clusters Indicator Survey, MIS Malaria indicator Survey, N number of individuals

aData not available

In terms of regions, the largest increase occurred in the Central-East and Central-South regions. The absolute increase in ITN use in the Central-East region was 75.9% points (p < 0.001), increasing from 2.6% in 2003 to 78.6% in 2014. The corresponding estimates for the Central-South region were 1.4% in 2003 and 75.4% in 2014 (p < 0.001) (Fig. 3).
Fig. 3

Trends of main usage indicators between 2003 and 2014, Burkina Faso. The proportion of the population (a), of children under 5 years (b) and pregnant women (c) who slept under an ITN the night before the survey is indicated for each region, for 2003, 2006, 2010 and 2014 respectively

Use of ITN among children under 5 years of age (P5)

In 2003, 1.9% (1.5, 2.4%) of children under 5 years of age were sleeping under an ITN, compared to 9.6% (7.6, 11.6%) in 2006, 47.4% (45.3, 49.5%) in 2010, and 75.2% (73.2, 77.3%) in 2014 (Table 5). Overall, the use of ITNs among children under five years has increased significantly from 2003 to 2014 (p < 0.001) (Fig. 1).

Analysis of ITN use by age band showed a significant increase from 2003 to 2014. In children younger than 12 months, use of ITNs increased from 1.9% in 2003 to 77.0% in 2014 (p < 0.001). Among children aged 12–23 months, the proportion that used ITNs increased from 2.2% in 2003 to 76.7% in 2014, suggesting an absolute increase of 74.5% points between the two periods (p < 0.001). Substantial increases in the use of ITNs also were observed in older children (ages 24, 36 and 48 months) from 2003 to 2014 (Table 6).
Table 6

Proportion of children under 5 years old who slept under an insecticide-treated bed net the night before the survey

Background characteristic

DHS 2003

MICS 2006

DHS 2010

MIS 2014

Percentage point change (2003–2014)

% (95% CI)

N

% (95% CI)

N

% (95% CI)

N

% (95% CI)

N

Age group (months)

 0–11

1.9 (1.2–2.6)

2153

11.3 (8.6–13.9)

1209

55.6 (52.4–58.8)

1517

77.0 (73.8–80.2)

1412

75.1 (71.8–78.4)

 12–23

2.2 (1.5–2.9)

1892

8.1 (5.7–10.4)

1069

54.6 (51.1–58.1)

1427

76.7 (73.8–79.5)

1314

74.5 (71.6–77.4)

 24–35

2.3 (1.4–3.2)

1819

10.2 (7.6–12.9)

1149

46.3 (42.7–49.9)

1426

74.7 (71.9–77.5)

1408

72.4 (69.5–75.3)

 36–47

1.9 (1.1–2.7)

2091

10.0 (5.0–15.0)

1060

45.4 (42.1–48.7)

1447

75.5 (72.7–78.3)

1419

73.6 (70.7–76.6)

 48–59

1.4 (0.7–2.1)

1867

7.7 (4.5–10.8)

796

45.2 (42.9–47.5)

8407

72.4 (69.1–75.7)

1369

70.9 (67.5–74.3)

Gender

 Male

1.8 (1.3–2.3)

5061

10.2 (7.5–12.9)

2677

47.9 (45.7–50.2)

7223

75.5 (73.3–77.8)

3506

73.7 (71.4–76.0)

 Female

2.1 (1.5–2.6)

4761

9.0 (6.9–11.2)

2604

46.8 (44.4–49.1)

7001

75.0 (72.5–77.4)

3416

72.9 (70.3–75.4)

Residence

 Urban

6.2 (4.4–7.9)

1631

23.8 (17.8–29.9)

573

45.5 (41.5–49.6)

3167

69.9 (64.8–75.1)

1051

63.7 (58.3–69.2)

 Rural

1.3 (0.9–1.8)

8191

6.2 (4.7–7.8)

4710

47.8 (45.4–50.1)

11,057

76.8 (74.7–78.8)

5871

75.5 (73.4–77.6)

Household wealth quintiles

 Poorest

1.2 (0.3–2.2)

1810

4.4 (2.5–6.4)

1255

41.2 (37.4–45.0)

2756

72.3 (68.4–76.3)

1528

71.1 (67.0–75.3)

 Poorer

0.7 (0.2–1.3)

2011

6.0 (3.7–8.3)

1100

46.4 (43.0–49.8)

2923

76.1 (73.1–79.0)

1570

75.3 (72.3–78.3)

 Average

0.8 (0.3–1.2)

2582

6.0 (3.8–8.2)

1306

49.2 (46.0–52.3)

3109

78.5 (75.4–81.6)

1604

77.7 (74.6–80.9)

 Richer

1.6 (0.6–2.6)

1748

9.4 (6.2–12.7)

1091

51.5 (48.1–54.9)

3086

78.3 (74.4–82.2)

1508

76.7 (72.7–80.7)

 Richest

7.0 (4.9–9.1)

1671

26.2 (21.5–30.9)

531

48.8 (45.1–52.6)

2350

69.7 (64.3–75.1)

712

62.7 (56.9–68.5)

Size of the household

 Small (1–5 members)

2.9 (1.9–3.9)

2365

15.4 (9.8–21.0)

1039

53.5 (51.1–55.9)

4853

77.9 (74.5–81.4)

2135

75.1 (71.5–78.7)

 Medium (6–8 members)

2.2 (1.4–3.1)

2633

10.0 (6.6–13.5)

1590

46.4 (43.6–49.1)

4634

78.2 (75.4–81.1)

2048

76.0 (73.0–79.0)

 Large (9+ members)

1.3 (0.7–1.9)

4824

6.5 (4.8–8.3)

2654

42.0 (39.0–45.1)

4737

70.7 (67.9–73.5)

2739

69.4 (66.6–72.3)

All estimates take into account sample weights

CI Confidence intervals, DHS Demographic and Health Survey, MICS Multiple Clusters Indicator Survey, MIS Malaria indicator Survey, N number of children

In urban settings, 6.2% of children under five years slept under an ITN in 2003, compared to 69.9% in 2014, indicating an absolute increase of 63.7% points (p < 0.001). In 2003, 1.3% of children under 5 years living in rural areas slept under an ITN. This proportion increased significantly in 2014, reaching 76.8% in children under 5 years living in rural areas (p < 0.001).

In wealth quintiles, the smallest increases were observed in children under 5 years from the richest wealth quintile, with an increase from 7.0% in 2003 to 69.7% in 2014 (Table 6).

Marked increases in ITN use were also achieved in all regions over the specified period; however, the Centre-East and Centre-Nord regions displayed the greatest increase in ITN use compared to the other regions with an increase from 2.5 to 86.5% and from 0.5 to 82.1% (Table 6, Fig. 3).

Use of ITN among pregnant women (P6)

The use of ITNs by pregnant women in Burkina Faso was 3.0% (1.9, 4.2%) in 2003, 44.5% (41.2, 49.%) in 2010, and 77.1% (72.9%, 81.3%) in 2014, indicating a significant increase from 2003 to 2014 (p < 0.001) (Fig. 1). In urban areas, 7.5 and 69.6% of pregnant women used ITNs in 2003 and 2014, respectively, an increase of 62.1% points (p < 0.001, Table 7). The corresponding estimates in rural areas were 2.1% in 2003 and 78.8% in 2014, a significant improvement in ITN use among pregnant women between these periods (p < 0.001). A trend similar to that of ITN use in children under five years was found when analyses were performed by wealth quintile.
Table 7

Proportion of pregnant women who slept under an insecticide-treated bed net the night before the survey

Background characteristic

DHS 2003

MICS 2006a

DHS 2010

MIS 2014

Percentage point change (2003–2014)

% (95% CI)

N

% (95% CI)

N

% (95% CI)

N

% (95% CI)

N

Residence

 Urban

7.5 (4.0–10.9)

219

38.3 (30.7–45.9)

378

69.6 (57.5–81.8)

6733

62.1 (49.6–74.7)

 Rural

2.3 (1.1–3.6)

1056

45.8 (42.2–49.4)

1310

78.8 (74.5–83.1)

31,660

76.5 (72.0–80.9)

Household wealth quintiles

 Poorest

1.1 (−0.4–2.7)

221

44.0 (37.5–50.5)

297

69.0 (60.8–77.2)

161

67.9 (59.6–76.2)

 Poorer

0.7 (−0.4–1.7)

269

42.5 (36.4–48.6)

369

78.5 (71.4–85.6)

8495

77.8 (70.7–84.9)

 Average

3.2 (0.4–5.9)

343

43.2 (37.1–49.2)

365

79.8 (72.9–86.8)

8520

76.7 (69.3–84.1)

 Richer

1.5 (−0.4–3.3)

216

49.1 (42.4–55.7)

358

87.8 (82.1–93.6)

8165

86.4 (80.4–92.4)

 Richest

9.4 (4.9–14.0)

226

43.9 (36.2–51.6)

299

65.5 (50.8–80.3)

4833

57.4 (42.2–72.5)

Size of the household

 Small (1–5 members)

4.3 (2.3–6.3)

442

47.0 (42.6–51.4)

813

75.8 (69.7–81.9)

11,250

71.5 (65.1–77.9)

 Medium (6–8 members)

2.0 (0.0–4.0)

350

42.1 (36.9–47.2)

463

78.3 (71.5–85.2)

12,025

76.3 (69.2–83.4)

 Large (9+ members)

2.5 (0.3–4.7)

483

42.2 (36.3–48.1)

412

78.4 (71.3–85.6)

15,118

75.9 (68.5–83.4)

All estimates take into account sample weights

CI Confidence intervals, DHS Demographic and Health Survey, MICS Multiple Clusters Indicator Survey, MIS Malaria indicator Survey, N number of pregnant women

aData not available

ITN ownership and use gaps

In 2003, 94.4% (93.5, 95.2%) of the study households did not possess an ITN (Fig. 1). Among those who owned at least one ITN, 67.0% (61.5, 72.4%) did not have sufficient bed nets to protect all members (intra-household net ownership gap). However, 19.4% (n = 94) of these households had excess ITNs (i.e., more than one ITN for every two people). A significant proportion (21.9%, n = 316) of the population with sufficient access to ITNs did not actually use them the night before the survey.

In 2010, 43.0% (41.0, 45.2%) of the study households did not have an ITN. The intra-household net ownership gap was 67.6% (65.8, 69.3%), indicating that about two-thirds of the households with at least one ITN did not have sufficient ITNs to protect all members. This gap is presented in Table 8 by background characteristics and shows that the gap was very high in large household size (93.4%) and rural areas (70.4%). However, 18.3% (n = 1475) of these households had excess ITNs (i.e., more than one ITN for every two people). A small proportion (12.7%, n = 3700) of the population with sufficient access to ITNs did not actually use them.
Table 8

Proportion of households owning at least one insecticide-treated bed net but with fewer than one net for every two household members (intra-ownership gap)

Background characteristic

DHS 2003

MICS 2006

DHS 2010

MIS 2014

Percentage point change (2003–2014)

% (95% CI)

N

% (95% CI)

N

% (95% CI)

N

% (95% CI)

N

Residence

 Urban

60.8 (53.8–67.8)

2182

53.5 (45.1–62.0)

921

58.7 (56.0–61.3)

4391

36.7 (33.5–39.8)

1305

23.9 (15.8–31.9)

 Rural

74.4 (66.8–81.9)

6868

76.2 (72.8–79.6)

4602

70.7 (68.5–72.9)

9997

48.9 (47.0–50.7)

5104

25.9 (18.2–33.7)

Household wealth quintiles

 Poorest

67.0 (51.0–82.9)

1880

82.5 (75.0–90.1)

1276

74.6 (71.4–77.8)

2620

51.3 (47.4–55.2)

1511

15.4 (−0.8–31.6)

 Poorer

90.5 (79.6–101.4)

1619

82.2 (76.0–88.5)

1276

71.1 (67.9–74.3)

2744

48.3 (45.1–51.5)

1385

42.1 (30.3–53.8)

 Average

80.4 (67.7–93.2)

2023

74.0 (67.1–80.9)

1116

70.2 (67.2–73.2)

2777

51.4 (48.1–54.7)

1288

28.7 (15.6–41.9)

 Richer

79.4 (66.6–92.2)

1407

77.6 (71.9–83.3)

1013

70.2 (67.2–73.3)

2922

44.5 (41.1–47.9)

1236

35.2 (22.7–47.8)

 Richest

59.2 (52.8–65.6)

2121

50.4 (42.9–57.9)

842

56.1 (53.4–58.8)

3325

33.3 (30.2–36.4)

989

26.0 (18.8–33.2)

Size of the household

 Small (1–5 members)

45.2 (38.2–52.2)

4421

41.2 (34.9–47.5)

2345

49.9 (47.8–52.1)

8169

25.5 (23.7–27.4)

3362

20.4 (13.3–27.5)

 Medium (6–8 members)

87.9 (78.3–97.5)

2401

76.6 (69.7–83.6)

1665

83.7 (81.7–85.7)

3911

59.3 (56.2–62.5)

1760

28.6 (18.0–39.2)

 Large (9+ members)

97.5 (94.5–100.5)

2228

94.7 (91.8–97.6)

1513

93.4 (91.7–95.1

2308

80.7 (78.0–83.4)

1287

16.8 (12.9–20.8)

All estimates take into account sample weights

CI Confidence intervals, DHS Demographic and Health Survey, MICS Multiple Clusters Indicator Survey, MIS Malaria indicator Survey, N number of households

In 2014, only 10.6% (9.2, 12.0%) of the study households did not have an ITN. The intra-household net ownership gap was 45.3% (43.6, 47.1%), indicating that about half of the households with at least one ITN did not have sufficient ITNs to protect all members. This gap was 80.7% in large household size and well above the national average (Table 8). However, 34.5% (n = 1926) of these households had excess ITNs (i.e., more than one ITN for every two people). A small proportion (5.9%, n = 1562) of the population with sufficient access to ITNs did not actually use them. In contrast, this proportion was 13.1% in urban areas and only 3.4% in rural areas (Table 9).
Table 9

Proportion of individuals with access to an insecticide-treated bed net who did not use them the night before the survey (behavioural gap)

Background characteristic

DHS 2003

MICS 2006a

DHS 2010

MIS 2014

% (95% CI)

N

% (95% CI)

N

% (95% CI)

N

% (95% CI)

N

Residence

 Urban

31.0 (27.9–34.1)

12,313

22.2 (21.2–23.2)

21,758

13.1 (12.3–13.9)

6733

 Rural

9.6 (7.3–11.9)

46,530

9.6 (9.2–10.0)

58,774

3.4 (3.1–3.7)

31,660

Household wealth quintiles

 Poorest

0.0b (0.0–1.2)

10,802

12.0 (11.1–12.9)

15,243

0.0b (0.0–0.0)

8380

 Poorer

8.9 (3.2–14.6)

11,113

9.9 (9.1–10.7)

15,389

4.4 (3.9–4.9)

8495

 Average

17.8 (11.9–23.7)

14,345

8.6 (7.9–9.3)

16,306

3.8 (3.3–4.3)

8520

 Richer

16.9 (10.9–22.9)

10,056

8.1 (7.4–8.8)

16,989

6.4 (5.8–7.0)

8165

 Richest

26.6 (23.8–29.4)

12,527

22.5 (21.5–23.5)

16,605

15.0 (14.0–16.0)

4833

Size of the household

 Small (1–5 members)

24.6 (21.2–28.0)

14,278

11.7 (11.1–12.3)

27,130

9.2 (8.6–9.8)

11,250

 Medium (6–8 members)

23.0 (19.1–26.9)

16,500

14.3 (13.6–15.0)

26,634

4.9 (4.4–5.4)

12,025

 Large (9+ members)

16.3 (12.7–19.9)

28,065

12.1 (11.4–12.8)

26,768

3.3 (2.9–3.7)

15,118

All estimates take into account sample weights

CI Confidence intervals, DHS Demographic and Health Survey, MICS Multiple Clusters Indicator Survey, MIS Malaria indicator Survey, N number of individuals

aData not available

bNegative gap values were set to zero

Discussion

The Government of Burkina Faso set a national goal to increase ITN ownership, access and use. These data provide evidence of the remarkable increase in the coverage of ITN ownership, particularly in 2014 after the second free distribution campaign. Indeed, ownership, access and use indicators calculated following MERG’s recommendations [21] dramatically increased between 2003 and 2014 and was particularly successful at reaching the poorest populations. The increasing trend in ITN ownership described here, is consistent with data from 19 SSA countries during a similar time period [26]. The data show that the two free distribution campaigns substantially increased ITN ownership and reduced inequity among populations in Burkina Faso. These findings are consistent with other free mass distribution campaigns that have been carried out in SSA [9, 27], demonstrating that this strategy can be used to rapidely scale-up ITN coverage in areas with low coverage and reduce social inequity. However, despite the significant progress, less than 50% of households own enough ITNs to protect every household members (Fig. 1). These campaigns should not represent the only mechanism by which ITNs are distributed to poorest communities and vulnerable populations [9]. In Burkina Faso, ITNs were provided for free to pregnant women and children under five years of age through routine channels, such as antenatal care and immunization campaigns. ITNs were also available for purchase in retail shops and stores. This could explain both the slight increase in bed net ownership (Fig. 1) and use (Fig. 3). However, the relative contribution of these distribution channels remains, to date, very limited. More than 90% of the ITNs were obtained during the free distribution campaign [25]. To reach and maintain high ITN coverage in Burkina Faso, there is a need to improve the contribution of the routine distribution through ANC and vaccination programs and develop alternative strategies, such as the continuous distribution of ITN in schools and by community health workers for replacement [28]).

Ownership and behavioural gap analyses provide complementary information regarding ITN ownership and use. The results reveal geographical and sociogeographic discrepancies of ITN ownership and use. Gap decreased (>10% point change) in all regions, with highest decreases in the Hauts-Bassins and, in the Sud-Ouest half of the country (zones where malaria transmission is permanent with a peak during the rainy season). Sahel, Nord and Centre-Est (where malaria transmission is seasonal) display lower gap reduction, but the ownership gap was already low in 2003. Change in malaria transmission may explain this difference. In 2014, geographical discrepancies in the ownership gap were minimum. Remarkably, the ownership gap increased in Centre-Nord. This increase can be attributed to the 2003 gap value, which is clearly an outlier: 35.8% gap, while the gap in all other regions fell between 59 and 90 (Fig. 4).
Fig. 4

Trends of ownership and behavioural gaps between 2003 and 2014, Burkina Faso. The proportion of households owning at least 1 ITN but less than 1 for every 2 members (a) and the proportion of people with access to ITN but who did not use it the night before the survey (b) is indicated for each region, for 2003, 2006, 2010 and 2014 respectively

By contrast with ownership gap, behavioural gap remained stable across the country. However, significant decrease was observed in Boucles de Mouhoun, Centre, Centre-Sud, and Centre-Est. All four regions displayed higher-than-average behavioural gap in 2003. In this respect, Centre consistently displayed higher behavioural gap values for all years studied, most likely because the population in this region is concentrated in urban habitat (Ouagadougou). This result could be explained by higher population dynamics in the capital region. Interestingly also, the change in behaviour is very recent in this region (in 2010, behavioural gap was 40%). In 2014, the behavioural gap was uniformly low across the country (0–15%). This reduction is probably a result of the health promotion programmes initiated by the Government of Burkina Faso to improve awareness concerning malaria prevention methods [25].

Household size is the main factor associated with ownership gap in this study. Large households with at least one bed net lacked additional bed nets to protect all family members (vs 25.5% for small households). Conversely, households in urban settings and from the richest quintile of the population more frequently owned enough bed nets than households located in rural settings or with a lower wealth index. This result is consistent with the findings of other studies showing that ITN coverage is lower in urban areas because mass distribution campaigns usually focus on rural communities [29, 30]. Therefore, future strategies for ITN distribution should pay partiuclar attention to urban areas.

Overall, the behavioural gap was very low in 2014. However, households located in urban settings and from the richest quintile of wealth index have higher gaps, because they might have other alternative prevention methods, such as better housing. Also, behavioural gap was significantly lower for large households which could result from large households having more family members (especially children) sleeping under the same bed net. The results showed that only a few large households possessed enough bed nets to protect all family members.

This study has a few limitations, however, they do not affect the validity of the results. This study was based on exiting data, and was limited by available data. Survey data were collected during different seasons of the year. MIS data were collected during the high transmission period while DHS data were collected during the end of the transmission period. This difference could potentially affect the trends analysis and may have under- or overestimated the effect size, as ITN use can be seasonal depending on the perceived nuisance of mosquitoes [31]. Furthermore, the measures presented in this paper were self-reported and therefore susceptible to social desirability biases.

Conclusion

Following the two free mass distribution campaigns in 2010 and 2013, Burkina Faso has made considerable progress in coverage of ITN ownership, access and use between 2003 and 2014. However, bed net coverage remains below national targets of 100% for ownership and 80% for use. To reduce significantly the malaria burden in Burkina Faso, the NMCP needs to increase further and sustained ITN ownership and use in the general population. The free mass distribution campaigns contributed effectively to increase INT ownership and use in Burkina Faso. The NMCP should continue implementing these campaigns to reach the universal coverage target. In addition, these campaigns should be complemented by other bed net distribution mechanisms (through antenatal care, immunization) to identify and replace nets that are worn, damaged or lost between free mass distribution campaigns. Furthermore, NMCP should have an effective behaviour change communication component in all distribution mechanisms to ensure that the population use bed nets consistently.

Abbreviations

ANC: 

antenatal care

RBM: 

Roll Back Malaria

BBC: 

behaviour change communication

DHS: 

Demographic and Health Surveys

EA: 

enumeration areas

LLINs: 

long-lasting insecticidal nets

MERG: 

Monitoring and Evaluation Reference Group

MICS: 

Multiple Indicator Cluster Surveys

MIS: 

Malaria Indicator Survey

ITNs: 

insecticide-treated bed nets

NMCP: 

national malaria control programme

SSA: 

sub-Saharan Africa

WHO: 

World Health Organization

Declarations

Authors’ contributions

FKS and SS conceived the study. SS and MP performed the statistical analysis. SS, FKS and MP drafted the manuscript. FKS and YY contributed to the manuscript by giving substantial intellectual inputs. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

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Authors’ Affiliations

(1)
Pôle Epidémiologie et Biostatistique, Institut de Recherche Expérimentale et Clinique (IREC), Faculté de Santé Publique (FSP), Université catholique de Louvain (UCL)
(2)
Spatial Epidemiology Lab (SpELL), Université Libre de Bruxelles
(3)
ICF
(4)
Centre de Recherche en Epidémiologie, Biostatistiques, et Recherche Clinique, Université Libre de Bruxelles
(5)
Plate-Forme Biostatistiques, Pôle Santé, Université Libre de Bruxelles

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