Tropical Health Matters

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.

I recently saw a posting on the HIFA2015 listserve that called for more culturally appropriate health information/behavior change communication in Kenya. Beatrice Muraguri a Health Information Officer with the Ministry of Health from Kenya observed, “barriers to LLINs use as an intervention in malaria control especially from Kenya’s Coastal region. In 2006 when we did our last mass distribution, refusals were many as rumours went round that the white rectangular nets were talking to the people and this hampered the use. We had to do a lot of social mobilization for acceptance.”

I discussed this experience with colleagues, one of whom asked if there was any overview of such net experiences from which programs could learn. In fact I am not aware of any broad based publication on cultural aspects of net use and misuse, but there has certainly been much information generated locally that is of anthropological relevant.

In a sense the challenge is that relevant information about nets is often quite localized. It would be useful to find out how much this information was gathered before major campaigns and actually used, and how much information was gathered after the fact when coverage was less than expected.

The concept of an ‘overview’ is in fact embodied in the anthropological process of inquiry that guides people to look for local perceptions and also hold the attitude to respect these local ideas, not as curiosities, but a alternative realities. When we deal with “local knowledge” we must consider the components of the perception – in this case we must consider how people perceive ‘malaria’ and in that context what are appropriate (if possible) preventive measures (not every group perceives ‘malaria’ as something that can be prevented in the western orthodox sense).

Then we need to consider perceptions of the nets themselves as well as the perceptions about insecticides/chemicals. In one setting nets may make people think of funeral shrouds, while in another they may appear to be wedding veils or fishing nets. People are always re-purposing artifacts from one culture to fit into what they perceive as relevant in their own.

So it is such ‘general lessons’ about how to obtain and use local knowledge that can be an overview or guidance.  We need to assume first and foremost that innovations like LLINs will just as likely NOT be seen by a local community in the same way that we western scientists see them.

There are also basic lessons from marketing. People reject products that are inconvenient or poorly designed.  People have always complained about nets restricting ventilation, and recent research has shown this to be true. Scientists have previously persisted with the ‘it’s good for you’ approach and assume people will do what is ‘good’. In contrast commercial companies are usually very sensitive to how people react to product function and design and try to find out what people think before expending great resources scaling up something in the market.

In the marketplace the customer may not always be ‘right’, but the customer does have the money. Since many public health interventions are free, we act as though people should be so grateful for getting those free commodities that they should not question how we tell them to use the nets. We forget that people are still public health ‘customers’.

So maybe there has not been a compendium written about net experiences from which one might draw lessons, but the basic anthropological skills exist and could be employed for each setting should program managers wish. Instead they often prefer to give IEC/BCC contracts to their friends and relatives to produce pretty posters at great cost that convey nothing meaningful to the public.

Maybe we can begin by sharing our experiences on listserve groups like HIFA2012 and our malaria update listserve and create a useful body of knowledge in terms of local approaches to improving net acceptance and use.This will work only if such feedback gets to the net designers and manufacturers!

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Philippa West and colleagues have demonstrated yet again that ownership of an insecticide treated bednet (ITN) does not guarantee that people are protected. Their study in Muleba District, one rural district in northwestern Tanzania points out the universal challenges of universal coverage.

In the study district the proportion of households (HH) owning ITNs increased from 63% to 91%.  The average number of ITNs per HH also rose from 1.2 to 2.1. The problem was that even with more nets in more homes, the proportion of residents actually sleeping under them did not rise to reach the desired target of at least 80%.  As an aside – statistical significance was achieved, but not program significance.

Here is what they found in the community from before and after universal coverage distribution:

• proportion of all residents sleeping under ITNs rose from 41% to 56%
• children under five years old – 56% to 63%
• pregnant women  – 55% to 63%

What was happening? One crucial finding was that 42% of households and fewer nets than the number of sleeping spaces and 20% had more than enough.  This speaks poorly to pre-distribution planning and HH registration or lack of care and verification during the actual distribution.

Another explanation documented by the researchers was that a fair number of HH did not redeem their net coupons at the distribution point – too busy, forgot, no transportation, etc. The program could have benefited from community directed distribution which guarantees that villagers take care of and ensure their own supplies of basic health commodities like ITNs.

These findings do not come as a surprise. Numerous reports from Demographic and Health or Malaria Indicator Surveys have shown a similar phenomenon – ownership of a net by the household does not guarantee that people actually use them.  In particular we can see this problem in the attached chart from the Tanzania 2010 DHS.

Fortunately the distribution in Muleba, though having problems, was equitable in terms of the economic status of recipients. Better planning, health education, community involvement and follow-up is required  if we are not to waste millions of dollars, not to mention lives, from poorly distributed nets.

Malaria in Pregnancy: A Solvable Problem—Bringing the Maternal Health and Malaria Communities Together – a meeting in Istanbul organized by the Maternal Health Task Force, Harvard University.

Take Away Messages from Day 2 Presentations by James Kisia, Kenya Red Cross.

The first roundtable of the second day was moderated by Koki Agrawal of MCHIP. Key lessons were the need to strengthen ANC as a platform for IPTp and ITN delivery. We need to address how to get the ANC systems funded—not just the interventions. Dr Agarwal challenged the panel to examine how to better measure processes that facilitate the delivery of care and to consider taking service beyond the walls of the health facility… and building stronger linkages between the facility and the community. We must develop indicators for quality of care and integration of programs

Viviana Mangiaterra of WHO explained that there are systematic issues in MIP; little investment has been realized (Global Fund has been doing most of the funding and is currently getting reorganized to increase technical guidance on MIP interventions as well as delivery mechanisms). There are different entry points – each provides opportunities for improvement in continuum of care. We must strengthen at different levels (for ex: CCM) to influence process

Mary Hamel of CDC demonstrated variations and contradictions in WHO guidelines on IPTp which can translate to country-level and implementation level confusion. She explained that, in the face of confusion, health workers are likely not to want to do harm—and, hence, do nothing. A simple clarifying memo from the Ministry of Heakth to health staff can help reach the desired level of IPT uptake.

Susan Youll of PMI talked about major challenges of poor data availability, stock outs. SP is not included in “tracer” commodity; not tracked in the same way other essential drugs are tracked. She discussed the negative effects of hidden fees for ANC services and the impact of this on IPT uptake and encouraged promoting the role of community to create demand.

Elena Olivi from PSI said of Nets that —“funding, funding, funding!” – is the answer. She reminded us of the overwhelming evidence that the biggest contributor to decrease in malaria cases was nets and cited by World Bank study on Kenya. Net delivery mechanisms are established and known. Nothing fancy about it! ANC is one of many platforms to deliver nets. She cited an example of nets treated like medicine with a prescription, enabling better tracking and forecasting. Behavior not an issue; knowledge about nets not a barrier to usage. There are technical champions for nets (PSI). The Advocacy community has not recognized the severity of the funding crisis—and lack of incentive to make bednets truly longlasting!

In conclusions, international partners have found that malaria in pregnancy cannot be controlled without basic resources and commodities. Advocacy is needed.

Keep up with MIP meeting on Twitter #MIP2012

Bill Brieger ?@bbbrieger – #MIP2012 universal coverage of ITNs not just to protect vulnerable groups against #malaria but also reduces mosquito population

Krisztian Magori ?@BiteOfAMosquito -bbbrieger: #MIP2012 MSF has found where no mass distribution of nets give pregnant woman 2… http://goo.gl/fb/xnHkd  – Bill Brieger ?@bbbrieger – #MIP2012 MSF has found where no mass distribution of nets give pregnant woman 2 nets ensure she gets to use at least one to prevent #malaria

bbbrieger: #MIP2012 non-use of nets related to real reduction in ventilation – both a design… http://goo.gl/fb/kdFMA – Bill Brieger ?@bbbrieger #MIP2012 non-use of nets related to real reduction in ventilation – both a design issue and an educational issue on net benefits #malaria

MHTF ?@MHTF – Challenges: Funding. Advocacy. ITN coverage in ANC. Incentives for net producers to make lasting nets.-Olivi Net @PSIHealthyLives #MiP2012

MHTF ?@MHTF – Net challenges: Funding. Advocacy. Limited ITN coverage in ANC. Need to incentivize bednet producers to make longer lasting nets. #MiP2012

Bill Brieger ?@bbbrieger – #MIP2012 Elena Olivi PSI need get manufacturers make stronger nets and new insecticides to deal with resistance #malaria; #MIP2012 Olivi PSI. even before when sufficient fund, not all ANC provided ITNs to protect pregnant women against #malaria

MHTF ?@MHTF We are in the midst of a funding crisis. Nets expire after 3 years & need to be replaced. -Olivi @PSIHealthyLives #MiP2012 #malaria #MNCH

Bill Brieger ?@bbbrieger #MIP2012 Olivi PSI: gap analysis underway to see countries at greatest risk of loosing ITN coverage gains #malaria

MHTF ?@MHTF Take homes: Nets save lives. African countries know how to deliver them. Technical champions exist. -Olivi @PSIHealthyLives #MiP2012 #MNCH

Sam Lattof ?@slattof Olivi: Writing women prescriptions for bednets relieves #ANC nurses of the duty, minimizes stockouts, and strengthens supply chain. #MiP2012

Bill Brieger ?@bbbrieger #MIP2012 Olivi PSI: challenges exist – we are in funding crisis and nets need replacement after 3 years. threat to MIP – risk loosing gains!

MHTF ?@MHTF Olivi @PSIHealthyLives: No need to get overly clever w/bednet distribution. Just do it. #MiP2012 #malaria #pregnancy #maternalhealth #MNCH

Bill Brieger ?@bbbrieger #MIP2012 Olivi PSI: Burundi experiment with ‘prescribing’ ITNs at ANC so woman collects from pharmacy. streamline ANC, better ITN tracking

Bill Brieger ?@bbbrieger #MIP2012 Elena Olivi PSI – ITN campaigns can reach poorer people, especially women who may not attend ANC or not yet start ANC #malaria

MHTF ?@MHTF Olivi @PSIHealthyLives: ANC best distribution channel of bednets for pregnant women. Other channels important for other groups. #MiP2012

Bill Brieger ?@bbbrieger #MIP2012 Elena Olivi PSI understanding of all kinds of ITN distribution channels and while ANC best for pregnant women, others can help

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.

As we have recently noted actual use of insecticide treated bednets (ITNs) by pregnant women in malaria endemic countries is not meeting targets.  In addition to tracking general coverage, we have reviewed Demographic and Health  or Malaria Indicator Survey (DHS/MIS) data showing that even in households that own nets, pregnant women may not be using them.

Now we need to take a step back and examine our indicators in light of the need to protect women fully. Two issues arise. First in the context of universal coverage, all women in a household should have access to sleeping spaces that have nets.  Women need strength before they become pregnant, especially younger ones who may be experiencing their first pregnancy.  Nets are one means of ensuring that women do not enter pregnancy already in an anemic state.

The second issue is pragmatic. Since a woman may not know for sure that she is pregnant in the early days and weeks of her pregnancy, she benefits from already being protected from malaria by nets that should have been provided through universal coverage. Intermittent preventive treatment can not be used with current drugs in the first trimester, so nets are the most important preventive measure during that time.

Even if a woman suspects she is pregnant, it is considered in many places culturally inappropriate for her to publicly announce or take public actions (like attending antenatal care) that let people know she is pregnant. If she waits in a culturally appropriate manner until ‘it shows’, she and the unborn child would have already been exposed to life threatening malaria infections. Universal coverage of nets prior to pregnancy maintains both the woman’s confidentiality and health.

To date few of the recent DHS/MIS have reported on net use by women of reproductive age (15-45 years) in general. The graph here shows a similar pattern for this group as observed for pregnant women. Problems of both access and use persist.

Because of the protection offered by ITNs in the earliest stages of pregnancy, it is extremely important not only for malaria endemic countries to undertake and maintain universal coverage that will reach women, but also track this as an important indicator of program success.

The push toward universal coverage of long lasting insecticide-treated bed nets (ITNs/LLINs) does not negate the fact that pregnant women are still a more vulnerable group that needs protection from anemia and death themselves and miscarriage, low birth weight and greater infant and child mortality for their offspring. So far the data on net coverage for pregnant women is not encouraging. Nets are extremely important because they are the one safe malaria control intervention that women can use right from the start of pregnancy.

Recent Demographic and Health and Malaria Indicator Surveys (DHS and MIS) show a common problem.  The graph here shows general access to LLINs is low (orange bars) in many countries relative to the Roll Back Malaria target of 80% coverage by 2010. What is of equal concern is that even when households possess nets, pregnant women do not always use them (blue bars).  Rwanda with its strong national network of community health workers is the exception. What is discouraging women?

The Liberia MIS asks why people do not own nets, and since these surveys prioritize interviewing women of reproductive age, we may assume that these reasons express the views of women.  A few do not perceive mosquitoes to be a problem (especially in the dry season), some simply do not like to sleep under nets while others complain of the cost.  The latter is curious because nets are primarily provided for free these days.

Clearly we need more information on the dynamics of net use at the household level.  Field visits after a universal coverage campaign in Akwa Ibom State discovered that women themselves see alternative uses of for nets.  One picture shows LLINs covering vegetable gardens that are tended by women in this community. Maybe they believe the nets will keep insects off their vegetables, although the sun will soon render the insecticide ineffective.

Another picture shows that a woman has protected the wares in her small kiosk buy covering it with a LLIN. Customers can still see the wares but insects can’t nibble at the food items on sale (nor children easily pilfer some).

Both of these examples highlight the economic roles of women in the community. Are women making net decisions on their perceptions of what is in their best economic interest? In most communities in Nigeria, income from a woman is crucial to the welfare of her child.

The issue of nets for pregnant women will be one of the issues discussed during the upcoming summit, Malaria in Pregnancy: a Solvable Problem—Bringing the Maternal Health and Malaria Communities Together, a meeting in Istanbul, Turkey, June 26-28, 2012, organized by the Maternal Health Task Force at Harvard School of Public Health.  We will be covering the deliberations as they unfold.

Currently the Roll Back Malaria (RBM) Partnership’s Malaria in Pregnancy Working Group is meeting in Kigali, Rwanda. Seven country teams present have presented their progress and challenges, including most recent information on coverage/use of long-lasting insecticide treated nets (LLINs) and intermittent preventive treatment for pregnant women (IPTp).  Other working group members have also presented coverage data from other countries.

Two main challenges emerged. First, for the most part stable endemic countries that are using IPTp and reporting recent levels of coverage for this and for LLINs are hardly reaching the 2010 RBM targets of 80%.  The second challenge is that some countries have actually recorded recent drops in IPTp coverage.

Group members presented experience and research that help explain these challenges.  Coverage with the minimum two doses of IPTp has been hampered by the following:

• periodic stock-outs of sulfadoxine-pyrimethamine (SP) supplies
• complexity of the steps involved in providing IPTp properly as directly observed treatment at antenatal clinic
• poor dissemination of national malaria in pregnancy (MIP) policies and guidelines
• inconsistencies in IPTp guidelines between malaria control and reproductive/maternal health service units
• lack of coordinated planning between those two units

The second problem, as seen in the chart to the left may be due to the above mentioned factors, but also imply more serious health systems problems. SP has become a forgotten step-child in the essential medicines portfolio.  Once reduced treatment efficacy was observed with SP, countries began switching to artemisinin-based combination therapy (ACT) for case management. SP was, according to meeting participants, still efficacious for prevention, but the formal health sector has not always responded by keeping it in stock.

In fact the private sector still stocks SP because customers demand this cheaper alternative to ACT, even though such unregulated use may add to the problem of parasite resistance.  Also donor programs, recognizing that SP is relatively cheap, often rely on endemic countries to purchase their own SP stocks, which some are reluctant to do.

IPTp saves lives in countries with stable malaria. The pregnant woman herself may not ‘feel’ the results of malaria that is concentrated in her placenta, but the fetus is deprived of nourishment and may be spontaneously aborted, stillborn, or born with low birth weight that increases the likelihood of neonatal mortality.

The 2012 World Malaria Day Theme of Sustain Gains, Save Lives: Invest in Malaria, could not be more timely in light of the charts seen here.  First we still have to make the gains in many countries, especially in respect to protecting pregnant women.  We need to sustain gains, not backslide.  This can only be done if donors and health ministries continue to fund MIP control activities and health program managers in both malaria control and reproductive health sincerely collaborate.

An update by Ogu Omede, National Malaria Control Program, Nigeria

Nigeria has targeted 64 million LLINs to be distributed. 45 million have already been distributed (71% of target). 28 states out of 37 completed with 9 left.

States lead the actual campaign implementation in collaboration with NMCP using the principle of the ‘three ones’: one plan, one implementation process, one monitoring mechanism.  The State Support Team (SST) is an implementation arm of NMCP that providea Technical Assistance for the LLIN campaign. This consists of 4 teams of 7 persons each; 3 workstream advisors and 2 overall coordinators. Distribution efforts are funded by DFID, USAID and World Bank.

Several challenges exist. There was inability to access operational funds from World Bank due to audit since September 2011.  There are inadequate stocks of LLINs in Millennium Development Goal States. Degradation of some storage areas has occurred.

Some states want to distribute this slow moving inventory without adherence to National Guidelines because of delays. Support operations face SST attrition, partner fatigue, and increased operational costs. There is even loss of nets that have been in storage for over a year.

The way forward can be achieved by getting support outside the WEorld Bank for now for 1) Operational funds, 2) Gaps in SST facilitation costs and 3) Procurement of LLINs to meet the gaps in MDG States targets

The NMCP and its partners are increasing support for the promotion of the net use culture which means undertaking Behavior Change Communication beyond the campaign period.  We are also encouraging transparent states and local government areas counterpart funding.