Tropical Health Matters

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.

For 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.

Study 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).

64% 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.

Results 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.

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”

SALIMA, 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 their 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.

The 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.

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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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.

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.”

Members 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.

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.

Some 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.

A new study from Zambia reports that despite mass distribution efforts towards achieving universal coverage only half the children in houses with nets slept under them the night before the survey. When the researchers checked for nets they discovered that, “… ITNs in poor condition are more likely to be observed hanging than ITNs in new or good condition.”

The proposed solution for this dilemma was, “In the context of free mass distribution of ITNs, behaviour change communication and activities are necessary to improve use. Results suggest campaigns and messages that persuade recipients to hang up their ITNs would contribute towards closing the gap between ownership and use.”

Coincidentally, another study set in several malaria-endemic countries examined the complaints that people often give when explaining why they do not use nets – ‘thermal discomfort’.

The researchers found that, “Bed nets reduce airflow, but have no influence on temperature and humidity. The discomfort associated with bed nets is likely to be most intolerable during the hottest and most humid period of the year, which frequently coincides with the peak of malaria vector densities and the force of pathogen transmission.”

Airflow is crucial because even a little breeze can make one feel cooler even if the temperature is not objectively different inside or outside the net. Not surprisingly denser mesh size reduced airflow even more.

These researchers took a different approach to solving the net use problem – instead of blaming the user, they suggested considering architectural issues like housing ventilation and net design issues that would increase airflow without jeopardizing protection against mosquitoes.

Sometimes it is the scientists, manufacturers and the program managers who need to change, not the community members.

http://www.wordle.net/create

On April 5th 2011 the Johns Hopkins Bloomberg School of Public Health observed Global Health Day. A key event was a series of poster presentations by students who had won global health grants to undertake field projects. Several were on malaria.  We are fortunate that the presentation below has been shared with us. Hopefully more will follow.

Use of Mobile Technology to Increase ANC Attendance and IPTp Uptake – Results from a Pilot Study in Uganda
Hsin-yi Lee, MSPH Candidate, Johns Hopkins Bloomberg School of Public Health

In search of innovative ways to increase IPTp uptake, the Stop Malaria Project (SMP) in Uganda wished to investigate whether mobile technology can be part of the solution. With nearly 42% of the population owning a mobile phone, mobile technology has demonstrated its incredible potential creates an impact at scale.

The SMP SMS pilot campaign was designed to address the issue of irregular Antenatal Care (ANC) attendance and low uptake of IPTp by sending out text message reminders to pregnant women and their close contact. The program was piloted at four facilities in Mukono District with 327 pregnant enrolled during their first antenatal visit.

Results from a post-campaign survey shows that after adjusting for control variables, program exposure remained a significant factor to determining ANC and IPTp completion rates. Respondents who received three to four messages had the highest odds for completing their ANC visits and were five times more likely to complete two doses of IPTp compared to those that received less than two messages.

Results also show that women whose husband or other contact had talked to them about the messages had higher ANC completion rates. The husband felt a “shared responsibility” about the women’s antenatal care by receiving the message on his phone. An unexpected outcome of the campaign was the clients increased trust towards the facility and health providers. Respondents from the survey had talked about how the messages showed that “the providers were responsible” and “caring.”

The Pilot SMS Campaign has demonstrated that text messages can play an effective role in promoting antenatal care attendance and uptake of IPTp. However, voice messaging methods should be further explored to overcome the issue of illiteracy. How to integrate a mobile health component into routine antenatal care in a resource limit setting is another pressing issue for program scale-up.

Further reading for similar mhealth programs:

• MoTECH  initiative – Ghana

• “Wired Mothers” – Tanzania

• Better Border Healthcare Program –Thailand

Many malaria partner organizations depend on the media to disseminate malaria information and generate support for their programs. And yet, unless the malaria organization itself issues carefully crafted press releases, interaction with the media can be challenging.

This week has seen two examples of the media getting it wrong on malaria-related stories. The first came from the Yemen Post from where reports of an impending malaria and polio vaccination campaign emerged. This was later clarified to be measles and polio, but not before many people wondered ongoing research on malaria vaccines had become operationalized so quickly.

A newspaper in Nairobi issued the second questionable story.  Supposedly a study had been issued that showed less than half the people in Nyanza were using their insecticide treated nets properly.  The Nairobi Star  said that people were not using nets because of taboos or were using them to protect their gardens. It is not that net misuse does not happen, but the scale that was reported, 51%, was startling.

In short order it was revealed that no such study had been done, but that the press had relied on anecdotal reports from a community group.  In fact health researchers familiar with the area, on reading the story raised another important issue – because there are no proper plans for disposal of old nets, it is possible some people were re-purposing those, not the new nets.

Mosquito misinformation is quite common. The press in Ghana often reports on the activities of sanitation companies and local government councils who are engaging in environmental management of vector breeding and claims this is malaria control. Their efforts to clear garbage and dirty gutters are commendable, but this work is aimed at other mosquitoes, not anopheles who tend to breed in clear, sunlit collections of water.

Malaria endemic countries often have many national and local newspapers, but this does not mean that they have adequate strength in professionally trained science and health journalists, who can spot the problems noted above, or at least be curious enough to check the facts.

Most times these stories go unread by the malaria community, but occasionally they can cause confusion and embarrassment when they misrepresent program activities. Monitoring the press after such stories are published is not the answer. Working with the press to help them understand malaria technical issues and activities is recommended.