title: Distance to health services influences insecticide-treated net possession and use among six to 59 month-old children in Malawi.
abstract: BACKGROUND
  Health ministries and providers are rapidly scaling up insecticide-treated nets (ITN) distribution to control malaria, yet possession and proper use typically remain below targeted levels. In Malawi, health facilities (HFs) are currently the principal points of ITN distribution, making it important to understand how access to these ITN sources affects ownership, possession, and use. The authors evaluated the association between proximity to HFs and ITN possession or use among Malawian children six to 59 months of age.
  
  
  METHODS
  A household malaria survey undertaken in eight districts of Malawi during 2007 was used to characterize ITN possession and use. The location of each respondent's household was geocoded as was those of Ministry of Health (MoH) HFs and other health centres. Euclidean distance from each household to the nearest HF was calculated. Patterns of net possession and use were determined through descriptive methods. The authors then analysed the significance of distance and ITN possession/use through standard statistical tests, including logistic regression.
  
  
  RESULTS
  Median distance to HFs was greater among households that did not possess ITNs and did not use an ITN the previous evening. Descriptive statistical methods confirmed a pattern of decreasing ITN possession and use with increasing distance from HFs. Logistic regression showed the same statistically significant association of distance to HFs, even when controlling for age and gender of the child, ratio of nets to children in household, community net possession and use, and household material wealth.
  
  
  CONCLUSIONS
  Strategies that exclusively distribute ITNs through HFs are likely to be less effective in increasing possession and use in communities that are more distant from those health services. Health providers should look towards community-based distribution services that take ITNs directly to community members to more effectively scale up ITN possession and regular use aimed at protecting children from malaria.
authors.affiliation: Department of Epidemiology, School of Public Health, University of Michigan, 09 Observatory, Ann Arbor, MI 48109-2029, USA. anfangen@umich.edu
authors.forename: Peter S
authors.initials: PS
authors.lastname: Larson
authors.forename: Don P
authors.initials: DP
authors.lastname: Mathanga
authors.forename: Carl H
authors.initials: CH
authors.lastname: Campbell
authors.forename: Mark L
authors.initials: ML
authors.lastname: Wilson
mesh_terms: D002675:Child, Preschool; D003430:Cross-Sectional Studies; D003695:Delivery of Health Care / Q000458:organization & administration; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D057148:Insecticide-Treated Bednets / Q000706:statistics & numerical data*; D008288:Malaria / Q000517:prevention & control*; D008295:Malawi; D008297:Male; D009032:Mosquito Control / Q000379:methods*