1. Assessing the Feasibility of Continuous Net Distribution in Kenya using Community Based Approach

2. Background Malaria control strategies are based on four principles Early diagnosis and treatment Use of effective medicines Sustainable preventive measures such as vector control- use of long-lasting insecticidal nets (LLINs)/IRS Detection, containment and prevention of epidemics

3. Approaches to increasing net coverage Use of LLINs have potential of saving half a million child deaths each year Sustained coverage and use of LLINs remains low Efforts to increase coverage include: o Social marketing o Catch-up -provision of free nets through clinics/ vaccination campaigns o Keep-up-combined strategy through provision of nets routinely to pregnant-women and children through public health clinics or commercial outlets/vouchers

4. Why a community approach? Shift from vulnerable populations to universal coverage Universal coverage- ratio of at least one LLIN for every two household members Sustaining universal coverage require innovative ways Continuous distribution systems are crucial to maintaining universal coverage Operational studies indicate the potential of using a community based model of sustaining universal coverage

5. Null Hypothesis Community based distribution of nets have no effect in sustaining universal coverage

6. General Objective To test the feasibility of sustaining universal coverage achieved during the mass net distribution through community based distribution

7. Specific Objectives To estimate the current number of nets per household in settings where mass distribution was implemented in 2011 To identify the number of nets in the household that need replacement To pilot and document the feasibility of using community based LLIN distribution schemes in maintaining universal coverage To assess whether community based redistribution schemes achieve higher utilization rates

8. Proposed intervention components Component 1: Establishment of HH registers CHWs under the supervision of CHEWS will develop a baseline village register containing HH details Component 2: Training of CHW/CHEW Identification of CHWs & CHEWS Training and sensitization on continuous LLINs distribution, their expected roles and responsibilities

9. Proposed intervention components Component three: Need determination LLIN need determination at Household level HHH approaches CHW for verification CHW gives a coupon to HHH to redeem a net from facility Component four: Advocacy and IEC strategies PHTs to conduct community awareness programs and integrate messages into health talks Use of active district ITN advocacy/ information, education and communication (IEC) groups

10. Schematic structure of net replacement process

11. Evaluation approach Type of evaluation /inference PerformanceImpact /Outcome ProvisionUtilisationCoverage Adequacy (changes occur) Are net available? Are nets being used? Is target population being reached? Were there improvements in patterns of use? Plausibility (effect above and beyond external influence) Does intervention area appear to perform better? Are there changes in behaviour that appear to be beneficial to intervention compared to control group? Probability (programme effect) Is intervention better than control group?Are changes in behaviour more beneficial to intervention than control group? What do you want to measure? How sure do you want to be?

12. Study design Quasi experimental utilizing a plausibility assessment of a before and after study with a control. Mixed methods- Quantitative- to assess the number of nets within the HH/ replacement, utilization of nets Qualitative -to assess the feasibility of using community based approaches to distribute the nets

13. Project sites Project site : selected community units in Samia District of Busia County Selection criteria : –Communities with a functional community health unit –similar malaria epidemiological profile, –Geographical buffer of about 20 km apart; –Has had mass net distribution taking place, –Malaria endemic with a prevalence of above 38 %. The district will be divided into intervention and control sites.

14. Sample size determination Expected effect: 10-20%, Cluster design approach-using a design effect of 2 95% confidence interval and 80% power, Estimated universal coverage 59.6% in western Kenya (Post Mass Net Evaluation report) Estimated sample size will be 876 per arm giving an estimated sample size of 1752 HHs in the two study sites

15. Summary of study activities MethodsTarget/No. involved sampling method Household survey House hold heads- 1752 Each household in EA selected Qualitative survey In depth interviews MoH=4Convenient sampling method Facility staff =3 Project implementation=2 Focus group discussions Community members-6

16. Data analysis Quantitative data from the HHs survey will be collected using android enabled phones/PDAs and submitted to a central server each day. Data verification, cleaning and analysis will be conducted using STATA version 11 Using USAID- Tool kit to track community – NetCalc version 2 to estimate coverage Qualitative data will be stored and managed using Nvivo10

17. Time line ActivitiesMonths 12345678 Proposal writing and review by the ethics committee XX Tool review and inputsX Field workXX Analysis of dataX Final write upX Dissemination activitiesX