Overcoming practical challenges to pilot Sierra Leone's first school-based distribution of piperonyl butoxide-synergist ITNs: findings from a 2023 assessment in Kono district.

Background: Continuous distribution of insecticide treated nets (ITNs) through schools is increasingly utilized by National Malaria Programmes across sub-Saharan Africa to maintain coverage between three-year mass distribution campaigns. In March 2023, the Sierra Leone National Malaria Control Programme (NMCP) piloted its first school-based distribution (SBD) in Kono district, reaching 88,605 pupils in 531 schools with piperonyl butoxide-synergist (PBO) ITNs. The pilot was assessed to determine changes in household and population ITN access and use, and to identify areas where future widescale SBD campaigns in Sierra Leone can be improved.

Methods: This was a mixed methods assessment. A cluster, multi-stage sampled household survey was conducted across 950 households, stratified post-hoc by presence (or not) of children eligible for SBD and powered to determine significant differences in ITN access among 'intervention' households (those with at least one eligible child) and 'control' households (those with no eligible children). Key informant interviews (KIIs) were conducted with 26 SBD stakeholders representing government, donors, third party logistics agencies and implementing partners.

Results: One- to two-months post SBD, a significantly higher proportion of households in the intervention group owned at least one ITN (93% versus 69%, p < 0.001) and at least one ITN per two people (42% versus 24%, p < 0.001). Population ITN access was significantly higher in the intervention group than the control group (69% versus 46%, p < 0.001). A higher proportion of the population also reported using an ITN the previous night in the intervention group (71%) than the control group (49%) (p < 0.001). KIIs highlighted resolvable challenges, particularly those related to untimely or insufficient funding, which led to subsequent issues for coordination, storage, transportation, quantification, distribution, training, microplanning and supervision.

Conclusion: Sierra Leone's SBD pilot significantly improved key ITN ownership, use and access indicators at the household and population levels in Kono district one- to two-months post-SBD. However, intervention population ITN use, and access were still below the NMCP's 80% target. Gaps should be addressed for SBD scale-up. Research on costing, sustained levels of ITN use and access, and the effect of SBD ITNs on malaria parasitaemia may be considered by the NMCP.