Category Archives: Communication

Documenting SBCC’s Important Role in Malaria Case Management

Community health worker Cheikh Tandian in southern Senegal during routine sweeps of villages with RDTs and ACTs. Photo by Ian Hennessee

Are there examples of effective social and behavior change communication (SBCC) for malaria case management that can be shared with other countries looking to improve their programming?

After examining research, policy documents and program evaluations from Ethiopia, Rwanda, Senegal and Zambia to determine whether effective SBCC activities have been used to improve malaria case management, I haven’t come across many strong examples. Program reports don’t tend to mention SBCC program evaluation. Reports that do mention it are difficult to find credible because the indicators used don’t address the real determinants of behavior.

Behavioral researchers have spent decades trying to illustrate just how insufficient it is to measure only knowledge. Attitudinal factors like perceived risk, self-efficacy and cultural norms are important behavioral determinants conspicuously missing from reports on malaria case management program design and evaluation.

Here’s an example of an attitudinal indicator related to malaria case management: Proportion of health care service providers that believe new diagnosis and treatment guidelines (test before you treat) are effective. I found a carefully designed study (a cluster-randomized controlled trial) assessing community health workers ability to diagnose and treat children. After a brief training, health workers evaluated over a thousand children with fever and accurately treated them based on disease classification 94%-100% of the time. Of note in this study: facility-based health workers (nurses or doctors) in two districts of the Southern Province of Zambia were less likely to follow guidelines or honor the results of rapid diagnostic tests than community health workers.

MalariaCare recently conducted a series of interviews revealing the same pattern. A 2014 systematic review on malaria in pregnancy found health care provider reliance on clinical diagnosis and poor adherence to treatment policy is a consistent problem. Perhaps doctors feel their considerable experience enables them to diagnose patients accurately without policy-mandated tests? Do community health workers adhere to a policy more tightly because they have a limited number of tasks and take pride in fastidiously carrying them out? The point is that the most educated individuals in an entire country – or those most likely to have accurate, timely information – can be outperformed by individuals with little or no formal education when exposed to the exact same set of government guidelines.

The difference is attitude.

Are programs targeting the attitudinal barriers behind adherence to malaria test results? Are evaluators measuring changes in these key attitudes? You can’t measure impact if you didn’t actually change behavior and people don’t change the way they act unless their decision-making process – in all of its beautiful human complexity – is acknowledged and addressed.

The Roll Back Malaria Partnership (RBM) has an SBCC community of practice made up of public health professionals working to promote a more rigorous, evidence-based approach to malaria SBCC program design and evaluation. One of the group’s products, the Malaria Behavior Change Communication Indicator Reference Guide, was developed to help Ministries of Health, donor agencies and implementing partners design and measure levels of behavior change related to malaria prevention and case management. The guide contains a list of indicators that go beyond knowledge and awareness into important behavioral determinants like attitudes. The guide has been available since February 2014 and this month the group is happy to announce its publication in Portuguese (it is also available in French and English).

The answer to the question posed by this desk review is that there is a lot of great work being done in malaria case management but it is being in done in a way that makes it difficult for others to follow. This new tool was developed to ensure SBCC programming is designed in such a way that its impact can be measured and replicated.

Journal of Indigenous and Community Communication (JICC)

Colleagues at the University of Ibadan have started on an important publishing endeavor as described below. Indigenous communication is an often neglected aspect of behavior change communication, and we hope this new Journal will bring more attention on how we can communicate about important health issues like malaria in ways that make sense to the community. Of course we also need to be willing to learn from the community first about their perceptions in order to have effective two-way communication:

Call for Papers for the Maiden Edition

JICCThe Editorial Board of the Journal of Indigenous and Community Communication (JICC) hereby invites original research articles, (empirical and discursive/expository), for the maiden edition of the journal that will be published in December 2014. JICC aims at offering space for scholars, researchers and development practitioners to contribute both qualitative and quantitative research findings in form of case studies, community-based situation analysis, reports of community-based interventions, evidence-based policy suggestions and intervention measures, and policy briefs. This volume will explore the theme of Community Communication and Poverty Reduction in Africa, with particular reference to the voices from community’s grassroots.

From recent researches,[1] the number of people living in absolute poverty in Africa is still high compared to most other low-income regions. Reasons given for the soaring numbers are diverse, ranging from leadership, irrelevant policies, failing institutions, human geography, among others. There are however many success stories from different African countries, stories that hardly get to find audience at the national and international levels, stories of people who through their daily struggle contribute to their betterment of their livelihoods.

This maiden edition is dedicated to how the community grassroots’ communication mechanisms contribute towards alleviating absolute poverty for those involved. Contributions to this edition should therefore centre on the efforts of knowledge and idea transfer at the very community’s basic level. Key questions around this focus include: In what ways do individuals get to exchange ideas about their own, and community’s development? Who takes initiative in the transfer of these ideas, and what informs this initiative? How (in)effective are these modes of communication? How can these grassroots, community-based communication initiatives become more widely accepted and engaged in dealing with poverty issues in African communities? What are the implications of these modes of indigenous/community-based communications with regards to reducing poverty in Africa?

Articles that explore these and other related questions, and especially field researches that are innovative and original are welcome.

Abstract submission

The first stage is to submit an abstract of a maximum of 300 words. In the abstract, indicate the gap that exists in literature and/or the key research question. It is important to link the key question to poverty and communication. Include the area (geographical) specificity of research in the case of empirical data and methodology, and how the findings will be useful in addressing/answering your research question. Include your name, institutional affiliation and email address. Once the editors have reviewed the abstracts, authors whose abstracts are accepted will be contacted to submit full papers. The deadline for abstract submission is August 10 2014. The abstracts should be submitted to: ayo.ojebode@mail.ui.edu.ng and mbusupa@yahoo.com

Article submission

Full articles should be written using the APA 6th style referencing. The words should be limited to 7,000 including footnotes and list of references (avoid providing bibliography). Briefings and policy briefs that provide review of specific country’s topical issues should be limited to a maximum of 3,000 words. Book reviews that are relevant to the theme of the edition should not exceed 1,000 words. Full articles for this volume are due November 15 2014.

JICC does not accept articles that are under consideration by other publishers. JICC does not compromise on matters of ethics and integrity. All academic articles will be peer-reviewed blind by three reviewers. An article is not recommended for revision unless it has at least two positive reviews. Two reviewers will review briefs and reports by organisations working in communities. JICC also strives to ensure that reviewers’ reports are turned in within six weeks. JICC conducts plagiarism checks on each article submitted to it. Any article that fails the test will be rejected and the author(s) will be barred from publishing in JICC in future.

JICC will be published availed online and in print.

Funding and Outlet

The Nigerian Community Radio Coalition supports JICC. However, we welcome support from other institutions and individuals in Africa and beyond.

JICC Editorial Board:

  1. Dr. Ayobami Ojebode – University of Ibadan, Nigeria
  2. Dr. Susan M. Kilonzo – Maseno University, Kenya
  3. Dr. Tunde Adegbola – African Languages Technology Initiative, ALT-I, Nigeria
  4. Prof. Holger Briel – Xi’an Jiaotong Liverpool University, Suzhou, China
  5. Prof. Kitche Magak – Maseno University, Kenya
  6. Prof. Christopher J. Odhiambo – Moi University, Kenya
  7. Dr. Birgitte Jallov – Empowerhouse, Denmark
  8. Ms. Jackline A. Owacgiu – Uganda/London School of Economics

[1]See for example Collier, P. Poverty reduction in Africa. Accessible at http://users.ox.ac.uk/~econpco/research/pdfs/PovertyReductionInAfrica.pdf. Collier’s book-The bottom billion: Why the poorest countries are failing and what can be done about it. New York, Oxford: Oxford University Press, explores this further.

Educating the Media on Malaria Control

The mass media – electronic, print and now social – play an important role in the fight against malaria.  The media reach diverse audiences from villagers to policy makers.  Because of their potential influence, the media must have the story right when it comes to malaria.

DSCN2402A news story published online this morning from a highly malaria-endemic country shows how some subtle but important mistakes can give wrong impressions and lead to wrong actions. The fact that the information is attributed to “medical science experts” does not mean that the reporters quoted them in the correct context.

The first example from the story is, “Spending on malaria and dengue fever treatment programmes should be controlled, with more efforts directed to preventive measures …”  As a disease caused by a virus, dengue does not have a definitive treatment, if by treatment we mean a cure.

Life saving palliative care is important in dengue, but dengue in Africa usually goes undiagnosed and is unfortunately often treated by wasting malaria drugs. The issue is not reducing treatment funds, but using rapid diagnostic tests so that we will not waste our expensive malaria medicines on non-malarial fevers.

The article next talks about how scientists in the country, “are advising the government to authorise controlled use of the banned pesticide DDT to strengthen mosquito eradication and bite control programmes in the country.”  DDT has been used for indoor residual spraying against the malaria carrying anopheles mosquitoes.  This fits into the anopheles behavior of resting on walls after biting.

By contrast dengue is carried by Aedes aegypti mosquitoes.  They are the ones that breed in pots, tins, etc. around the house, and DDT is not a major part of the efforts to control them. Household members are responsible for removing or not even allowing such small collections of water to occur in their houses, on their property and among their neighbors.

A final odd claim is that, “Donor funded health programmes are disadvantaged because the in-country implementers ‘accept each and every thing directed to them by the donors without challenging their ideas.’” For the biggest malaria funding programs this is not true.  The Global Fund for years has required that countries submit their own proposals that were developed and passed through their own national country coordinating mechanisms.

Now Global Fund is requiring countries to submit their own national malaria strategies as a basis for funding. The Global Fund is a financial organization, not a technical one, and thus is not directing countries what to do other that spend their money well on scientifically sound interventions.

Other donors work together with national malaria control programs and their partners to develop country specific and relevant operational plans. Donors do encourage countries to implement scientifically proven guidance that is developed by international technical committees whose members include scientists from endemic countries.

The points above could create unfortunate misunderstandings by the public (about insecticides), professionals (about treatment) and policy makers (about donor support). The media should foster appropriate and timely action against malaria, not confuse the public.

Behavior Change for Malaria: Are We Focusing on the Right ‘Targets’

Two articles caught my attention this morning. One reviewed the merits of improved social and behavior change communication (BCC) for the evolving malaria landscape. The other addressed the damage institutional corruption is doing in Africa. And yes, there is a connection.

When I was trained as a community or public health educator in the MPH program at UNC Chapel Hill, the term BCC had not yet been coined. We were clearly focused on human behavior and health.  What was especially interesting about the emphasis of that program was the need to cast a wide net on the human beings whose behaviors influence health.

DSCN7742 CHW flipchart

BCC of individuals and communities may not be enough

While the authors in Malaria Journal state that, “The purpose of this commentary is to highlight the benefits and value for money that BCC brings to all aspects of malaria control, and to discuss areas of operations research needed as transmission dynamics change,” a closer look shows that the behaviors of interest are those of individuals and communities who do not consistently use bed nets, delay in seeking effective treatment, and do not take advantage of the the distribution of intermittent preventive therapy (IPTp) during pregnancy. The shortfalls in the behavior of other humans is lies in not “fully explaining” these interventions to community members.

The health education (behavior change, communications, etc. etc.) program at Chapel Hill taught us that a comprehensive intervention included not only means and media for reaching the community, but also processes to train health workers to perform more effectively, to advocate with policy makers to adopt and fund health programs, and intervene in the work environment using organizational change strategies to ensure programs actually reached people whose adoption of our interventions (nets, medicines) could improve their health.

At UNC we tried to focus change on all humans in the process from health staff to policy makers to ensure that we would not be blaming the community for failing to adopt programs that were not made appropriately accessible and available to them. We did not call it a systems approach then, but clearly it was.

This brings me back to the article on corruption. Let’s compare these two quotes from the IRIN article …

  • The region accounts for 11 percent of the world’s population, but carries 24 percent of the global disease burden. It also bears a heavy burden of HIV/AIDS, tuberculosis and malaria but lacks the resources to provide even basic health services.
  • Poor public services in many West African countries, with already dire human development indicators, are under constant pressure from pervasive corruption. Observers say graft is corroding proper governance and causing growing numbers of people to sink into poverty.

Illicit cash transfers out of countries and bribery of civil servants, including health workers, are manifestations of the same problem at different ends of the spectrum resulting in less access to basic services and health commodities.  Continued national Demographic and Health Surveys show that well beyond 2010 when the original Roll Back Malaria Partnership coverage targets of 80% were supposed to have been achieved, we see few malaria endemic countries have achieved the basics, and some have regressed. Everyone is bemoaning the lack of adequate international funding for malaria (and HIV and TB and NTDs), but what has happened with the money already spent?

Without a systems approach to health behavior and efforts by development partners to hold all those involved accountable, we cannot expect that the behavior of individuals and communities will win the war against malaria.

Impact of behavior change communication on promoting parasite-based diagnosis for malaria

Encouraging both health workers and their clients to use and accept malaria rapid diagnostic tests can be a challenge. Esther Kaggwa, Douglas Storey, John Baptist Bwanika, Angela Acosta, Ron Hess, Emily Katarikawe, Espilidon Tumukurate, Julian Atim, Daudi Ochieng and Matthew Lynch of the Johns Hopkins University School of Public Health Center for Communication Programs addressed the RDT issue at the American Society of Tropical Medicine and Hygiene 62nd Annual Meeting in Washington DC. Their work is summarized below.

Fig1For 2-3 decades, presumptive treatment of malaria was widely practiced. In 2011, only 26% of Ugandan children under 5 with fever in the past 2 weeks received a blood test for malaria.[1] The new WHO policy of parasite·based diagnosis and treatment requires a major change irl household’s case management behaviors.[2]

The “Power of Day One” is a behavior change communication campaign (BCC) promoting testing and treatment for malaria within 24 hours of fever onset for pregnant women and children under 5 in Uganda. It started in June 2011 and ran in six districts: Apac, Katakwi, Kumi, Ngora, Serere and Soroti. Activities included provision of subsidized RDTs, provider trainings, promotion of new services, billboards, community dialogues, home visits, radio spots, a phone hotline, and others.

Fig2Study respondents were selected using multi-stage random sampling that selected not more than 300 persons per district. This sub-analysis included 847 individuals in 3 campaign districts that participated in the survey (Apac, Kumi, and Soroti). Results were analyzed using propensity-score matching to create matched control and experimental groups since exposure to media could not be randomized. The effect of any exposure to Power of Day One and in combination with other malaria campaigns was assessed. Logistic regression controlling for age, gender, wealth index, marital status, education, and rural or urban residence measured the association between level of exposure to Power of Day One and testing for malaria among respondents who had family members with a fever in the past two weeks (n=296).

Fig364% of respondents reported having seen or heard Power of Day One messages during the 12 months preceding the survey. Exposure was higher among respondents from urban areas (80%), those with more than secondary education (84%) and those from the highest wealth quintile (72%).1t was lowest among females aged 35-44 (53%) and respondents with a primary education (58%). 90% of those exposed to Power of Day One correctly recalled a specific message about testing and treatment for malaria within 24 hours.

49% of family members of respondents exposed to any malaria communication campaign that promoted Family members of respondents exposed to Power of Day 1 messages were 71% more likely to get blood drawn from a finger or heel for malaria testing when they had fever compared to those who were not exposed (p<0.001 ), primarily among women. Family members of respondents exposed to 2 or more communication channels were 1.3 times more likely to get tested for malaria than those not exposed.

Fig4Results indicate that communication can boost uptake of testing for malaria. Level of exposure was
also associated with behavior change. Further research on role of communication in promoting adherence to test results is needed.

The survey had some limitations in that the assessed testing behavior related to any family member with fever instead of just children under five. Households’ care-seeking behaviors for young children may differ from that for adults and other family members. Some of the observed effects may be due to other malaria programs, such as trainings on integrated community case management for community health workers which may have also taken place during the evaluation period.

This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responslbllity of the presenter and do not necessa rily reflect the views of USAID or the United States Government.

References

  1. World Health Organization {WHO). 2012. T3:Test. Treat. Track Initiative, 24 Apri12012. Avallable: http://www.who.lnt/malarla/test_treat_tracklen/index.html. Accessed: 2012 July 5.
  2. Uganda Bureau of Statistics {UBOS) and ICF International inc. 2012. Uganda Demographic and Health Survey 2011.Kampala, Uganda: UBOS and Calverton, Maryland: ICF International Inc.

Malawi Vice President Launches the 2013 SADC Malaria Day

Daniso Mbewe, the Knowledge and Information Management Officer of SARN has shared with us a Press Release from the Southern African Regional Network Secretariat (SARN) of the RBM Partnership in Southern Africa. The commemoration was held under the THEME: “Be free of Malaria in SADC Region”

Vice President of Malawi SADC Malaria Day 2013 smSALIMA, MALAWI,  08 November, 2013: The Vice President of Malawi, Rt. Hon. Khumbo Hastings Kachali, launched the 2013 SADC Malaria Day Events in the malaria endemic Lake Malawi town of Salima. The events were attended by Health Ministers and senior health officers and national malaria managers from SADC countries (Angola, Botswana, Lesotho, Malawi, Mozambique, Namibia, Tanzania Mainland and Zanzibar, Zambia and Zimbabwe, SADC Secretariat, SARN Secretariat, USAID, the uniformed Forces (military/police), RBM partners, provincial, district and local political, religious and traditional leaders, communities and school children.

The presence of traditional dance troops, dreamers, actors (drama troops) and school children made the event colorful and highly entertaining. Of special mention is Illovo Sugar a member of the SARN private sector constituency which donated 1 million Malawi Kwacha for the event and provided a demonstration of the T3, IRS, LLINs, IPTP and BCC/IEC.

Senior Chief Kalonga thanked SADC and the Malawi government for bringing the event to his region because Salima has a lot of malaria which is impacting on development especially workers, school children, pregnant women, teachers and fishermen. He thanked the National Malaria Control Program for distributing LLINs and other interventions which are on-going in his region.

Malawi Minister, Hon. Catherine Gotani Hara – emphasized the need to continue protecting the women and that they should attend ANCs and demand for malaria protection while encouraging all members of the family and community to report early for treatment. She thanked the RBM and partners for the continued support and technical guidance from  the WHO.

The Rt. Hon Khumbo Hastings Kachali, the Vice President of the Republic of Malawi, a former Minister of Health said that he was informed that there is now a trend showing a decrease in cases and deaths in Salima and he would like to see this replicated nationally. He however, warned the communities that this could be derailed by those people who use nets for fishing (Salima is a fishing community), sell nets, do not sleep under nets, do not complete theiSADC Malaria Day 2013r treatment and women who refuse to take IPTp. By 2015 he said  “Malawi should have distributed over 10 million LLINs” much to the applaud of the participants.

The Vice President thanked SADC Member States and all those who attended and that this level of collaboration, interaction and information sharing should continue to blossom. He further emphasized that the attainment of the MDGs is a priority for all SADC countries and as the SADC chair, Malawi will continue to encourage countries and also to appraise the Heads of States on progress made and challenges the Ministries of Health are facing especially domestic funding, health infrastructure, equipment, shortage of human resources and skill levels.

The main outcome was high and community levels advocacy, SARN-RBM visibility, regional collaboration and community education via several drama/plays with malaria themes and messages.

MIM Pan-African Malaria Conference is Coming

MIMThe main program for 6th MIM Pan-African Malaria Conference is available at the Medical Research Council website: http://mim2013.mrc.ac.za/programme.htm. We will be using #MIM2013 to share tweets. The conference runs from 6-11 October 2013 in Durban, South Africa. There will be a variety of presentation formats including Plenaty sessions, symposia, parallel scientific sessions and poster sessions/exhibits.  Many partners will be hosting special events.

Plenaries will highlight the current status of malaria intervention as well as look toward the future. In that vein several sessions address malaria elimination as for example …

  • Plenary Lecture VII by Prof Alan Magill “Strategies for realising malaria elimination and eventual eradication”
  • Plenary Lecture V by Dr Robert Newman“From a one-size-fits-all to a tailored approach for malaria control and elimination.”
  • Symposium 19: Targeting malaria elimination in Zanziba. Prof Anders Bjorkman
  • Symposium 58: Malaria eradication: identifying and targeting the residual parasite pool Mr Simon Kunene
  • Symposium 41: The final decade of malaria in Africa: planning for the endgame

There are sessions on case management issues ranging from severe malaria to better diagnostics. The role of the private sector is addressed. Vector biology and entomology are featured.

Not only will there be formal media coverage of events, including interviews with key players in malaria control and elimination, but the Roll Back Malaria partnership is mobilizing its Working Group members and partners to provide a full range of social media exposure for MIM events on Facebook, twitter and various blogs.  Keep your eyes on this page for the latest updates as news is being released.

Health Literacy as a component of primary care in Ante-natal and Pediatric clinics in Northern Nigeria

This guest blog is re-posted from the course blog for Social and Behavioral Foundations of Primary Health Care. The lesson about health literacy pertains as much to malaria as it does to cholera and handwashing. We thank Elohor Okpeva for sharing these experiences.

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Image

Source: Jimmy Nyambok/USAID

In September 2011, there was a cholera epidemic across several States in Northern Nigeria, notably Yobe and Borno States. The Federal and State health Ministries were certainly overwhelmed and ill-equipped to handle the challenge. Repeated outbreaks of preventable diseases are not uncommon.

The Centers for Disease Control and Prevention (CDC) describe cholera as a disease caused by the bacteria vibrio cholerae, rare in industrialized nations, yet on the increase in many other places including Africa. It is a life threatening disease but easily preventable.

As a nation, Nigeria pledged to fulfill the indices of the MDGs. The fourth index of the MDG elaborated in the child survival strategies lists health education as its component. Locally, the Federal Ministry of Health also developed the National health promotion policy.

Following the cholera outbreak of September 2011, an informal health education session in the pediatric clinic at the Umaru Shehu Ultramodern Hospital (Maiduguri, Nigeria) with focus on hygiene was undertaken by a corps’ Doctor. The women listened with rapt attention, often accompanied by incredible nods, as they were told the benefits and impacts of hand washing in curtailing the disease. It was an unfamiliar message.

The Nation’s leaders, health team and key affiliates must recognize the crucial role of health education in general public health. The maintenance of a healthy status begins with prevention and not clinical treatment. The advantages of disease prevention and consequent reduction in morbidity and mortality cannot be over-emphasized.

Ghana Footballers Fight Malaria

News from Ghana by Emmanuel Fiagbey, Ghana Malaria Voices Project:
The Ghana Football Association (GFA) has held a special media event in Accra to highlight Ghana’s progress in the fight against malaria with support from the National Malaria Control Program and the Voices for a Malaria Free Future project of Johns Hopkins University’s Center for Communication Programs.  Just as in the previous Africa Cup of Nations (AFCON), the 2013 event will promote United Against Malaria (UAM) – an international effort for using football to draw attention to and mobilize support for malaria control efforts.

GFA’s 7th September media event was a prelude to the Ghana–Malawi qualifying match and attracted representatives from 21 print and broadcast outlets and malaria-related agencies and NGOs.

The event was opened by GFA’s president Mr. Kwesi Nyantakyi who reminded those present that …

“Because of GFA’s national reach, Mr. Nyantakyi promised to work towards bringing on board the UAM Partnership local football clubs which belong to the Ghana League Clubs Association to support dissemination of important malaria prevention and treatment messages in communities all over the country.”

a-journalist-poses-her-question-uam-20120907-sm.jpgMembers of the Ghana Media Malaria Advocacy Network (GMMAN) and other journalists who participated in the event were very enthusiastic in continuing to disseminate malaria information through their publications. They however called on the Voices Project to keep them regularly posted on developments at the malaria front.

Maybe the GFA’s enthusiastic support for United Against Malaria helped propel them to success as Ghana Beat Malawi in AFCON 2013 Qualifier a few days later!  Of course no national FA in Africa can afford to ignore the threat of malaria to their teams or their communities.

More on Insecticide Treated Bednet Experiences

In response to our blog on malaria and bednet perceptions, Stephen Goldstein of Johns Hopkins University’s Center for Communications Programs (JHUCCP) offers a compendium of experiences gleaned from their K4Health’s newly re-designed POPLINE database. Here are Stephen’s findings …

While many of the articles cite reasons of cost or concerns about safety and effects of chemicals, some mention that sleeping under them was too hot, and that they were used more during the rainy season than the dry.

super-market-3a.jpgSome other lessons:

  • Treated nets were more likely to be used than untreated ones;
  • Nets two years old or less were more likely to be used than older nets;
  • Nets that were paid for were more likely to be used than nets obtained for free;
  • Larger nets were more likely to be used than smaller ones, except in Ethiopia;
  • The more nets a family owned, the less likely that all of them would be used.

Other information from the articles include:

In Uganda a project to test the accuracy of reporting about bed net use was carried out through a questionnaire sent to schools vs. a more traditional and more expensive community survey method.The study concludes that in areas with high school attendance rates, school children’s report of bed net use monitored by school teachers could give a good approximation of household ownership of bed nets at community levels with about ±5% difference between community and school surveys.

In Timor-Leste, there was a widespread perception that nets could or should only be used by pregnant women and young children, and extensive re-purposing of nets (fishing, protecting crops) was both reported and observed, and may significantly decrease availability of nighttime sleeping space for all family members if distributed nets do not remain within the household.

In some parts of Kenya, despite insecticide treated nets ownership reaching more than 71%, compliance was low at 56.3%.

In Zambia, some bed net distribution strategies missed households occupied by the elderly and those without children, resulting in overall low use as well as a perception that the insecticide-treated mosquito nets wore out before they could be replaced.

In Tanzania, while 65 percent of some 200 respondents were aware of the use of insecticide treated nets (ITNs), the coverage of any mosquito net and ITN was 12.5% and 5%, respectively. Affordability, unavailability and gender inequality were identified to be major factors associated with the low ITN coverage.

As the body of information and knowledge about use and non use of ITNs becomes available one hopes that it will be easier for the “basic anthropological skills” to be employed by program managers and that “the pretty posters that convey nothing” will be a thing of the past.