Senegal's first nationwide free distribution of LLINs coupled with mebendazole and vitamin A reached 75% of children < 5 with an LLIN, and over 80% of children < 5 with vitamin A and mebendazole. Though falling slightly short of its objective of reaching 85% of targeted children, the campaign increased overall household ownership of at least one ITN to over 80%. This campaign was different from previous nationwide campaigns reported in the literature [11
] in that it was not integrated with a vaccination campaign; however, it appears to have had comparable results in terms of coverage of eligible children. Despite concerns that omitting distribution to children under six months would leave these children unprotected, an apparent redistribution in and among households covered these vulnerable children after the campaign.
The majority of children who did not receive the campaign interventions were those whose guardians reported neither receiving a visit at home nor going to a distribution point, followed by children who were not present at the time of the campaign. While the door-to-door distribution of vouchers for later redemption of an LLIN reached a majority of households, almost one-third of caretakers reported receiving campaign interventions through different strategies, either receiving all interventions simultaneously at the house, or more frequently, being requested to go to a central distribution point for all interventions. Of those that received vouchers door-to-door, almost all went to a distribution point to get an LLIN, and were able to exchange their vouchers. The distribution points appeared to have been well-placed, with most respondents reporting a distribution point in their villages, travelling on foot to arrive in under 30 minutes.
Although there have been anecdotal reports from some countries of campaign LLINs being sold in the market or unused after campaigns, in Senegal the overwhelming majority were reported to have remained in the household and were being used. Of the few that did not remain in homes, most were reported given away to family or friends; not one was reported sold, consistent with what was seen in Niger [18
While this campaign targeted children 6-59 months of age, Senegal has a policy of universal coverage, or high access to and use of ITNs by all age groups. Of ownership indicators of universal coverage, just under 40% of households have at least one ITN for every two people, and approximately 20% have one ITN per sleeping space. Despite high household ownership of at least one ITN, households still own only half the number of ITNs needed to cover every sleeping space. The results suggest that regions that had not had previous campaigns largely "caught up" with regions that benefitted from previous LLIN distributions in terms of household ownership of at least one ITN and partially caught up in terms of ratio of ITNs to household members or sleeping spaces. While households in rural areas with one or more children < 5 have exceedingly high household ITN ownership, household ITN ownership is lower in urban areas and in households without children < 5. The equity analysis demonstrates the continued importance of providing free LLINs. Though the lowest quintile has a higher proportion of households owning at least one ITN, they have fewer ITNs per household member than the highest quintile. In addition, the highest quintile largely overlaps with the urban population, where families state they rely on screens, fans, mosquito coils, and other non-ITN interventions, while the rural poor rely principally on nets. A review by Kilian of published and gray literature evaluating LLIN distribution strategies found that high household ITN ownership results in high equity, with campaigns achieving rapid increases in net coverage and increases in equity of net ownership [13
Utilization rates for ITNs were relatively low given the high level of ownership in comparison with other reports [11
]. While the proportion of houses with at least one ITN is high, given the large median household size, only a minority of households have enough ITNs to allow every member to sleep under one. Also, both this survey and the previous Senegal Malaria Indicator Survey were conducted at the beginning of the dry season, when usage has been noted to be lower [22
]. In Niger, ITN usage during the dry season immediately after the campaign was found to be three-fold lower than during the following rainy season, and in Togo, dry season usage was also significantly lower than rainy season, though not as strikingly [11
This study had a number of limitations. As noted above, the reported rates of utilization may be low because the survey was conducted during the dry season. While not capturing optimal usage, this timing still allows for an assessment of effectiveness of the campaign in reaching its distribution targets, progress toward goals in ITN ownership, and equity of ITN ownership. As with most other surveys examining ITN use, there was no verification as to whether the person in question actually slept under the ITN the night before the survey. Though in a few cases, the existence of the net in question was not verified, people may be more likely to under-report nets in hope of being given another, underestimating ownership. While the vast majority of vouchers were reported exchanged for an LLIN, and most LLINs were reported to remain in the homes of the recipients, this was self-reported, and may have been prone to recall or reporting bias. Data on campaign participation was missing for 6.2% of all children, however the proportion of these children who slept under nets acquired from the campaign was similar to children for whom data was available, thus it is unlikely that the missing data biased the results.
Senegal is now embarking on a nationwide rolling campaign targeting universal coverage, distributing one LLIN per sleeping space. The results of this campaign evaluation have been fundamental in the planning of the universal coverage campaign. At the same time, the NMCP is strengthening behaviour change communication programs to ensure people use the nets they have available. These efforts hopefully will close the remaining gaps in ITN possession and use in Senegal and enable the country to achieve truly universal coverage.