A malaria control trial using insecticide-treated bed nets and targeted chemoprophylaxis in a rural area of The Gambia, west Africa. 4. Perceptions of the causes of malaria and of its treatment and prevention in the study area

Dynamics in ownership, access and use of long-lasting insecticidal nets in Togo: Evidence from three population-based surveys

Malaria remains a major public health problem in many countries in Sub Saharan Africa, including Togo, particularly among children under 5 years of age. Therefore, several mass distribution campaigns of long-lasting insecticide-treated bed nets (LLINs), which constitute an essential preventive strategy, have been conducted. The aim of this study is to assess progress in terms of equity of ownership, access and use of LLINs in a context of universal coverage among households in Togo.Data from the Togo Multiple Indicator Cluster Survey (TMICS) of 2010, the Togo Demographic and Health Survey (TDHS) of 2013-2014, and the Togo Malaria Indicator Survey (TMIS) of 2017 were used. For each survey, three main LLIN indicators were calculated: ownership (defined as % of households owning at least one LLIN), access (defined as % of households owning at least one LLIN per two people), and use (defined as use in the night before the survey by any household member). Trends from 2010 to 2017 were assessed by calculating the percentage point change between 2010 and 2017. A multivariate analysis was performed to identify factors associated with the use of LLINs in under five children. Nationally, between 2010 and 2017, LLIN ownership increased from 56.0% [54.4-58.2] to 85.0% [84.1-86.0]. LLIN access increased from 28.3% [27.0-29.2] to 71.0% [70.1-73.1], with little heterogeneity between regions. LLIN use increased from 37.1% [36.2-38.6] to 63.0% [62.5-64.7] in the whole population, with a similar trend observed among under five children. Region and type of housing showed a significant association with the use of LLINs in under five children. Considerable progress with regard to ownership, access and use of LLINs between 2010 and 2017 was observed in Togo, although LLIN coverage remained below the national targets of 100% for ownership and access for each member and 80% for use. The reduced inequity suggests efforts were well targeted to those most in need. These results can support both future policy decisions and downstream analyses of malaria prevention.

Effect of a novel house design (star home) on indoor malaria mosquito abundance in rural Tanzania: secondary outcomes of an open-label, household, randomised controlled trial

BACKGROUND

Screening houses can reduce malaria transmission in sub-Saharan Africa. Our study evaluated whether a novel screened house design (star home) with bedrooms on the second storey reduced indoor mosquito abundance compared with traditional houses in Mtwara, Tanzania.

METHODS

In this open-label, household, randomised controlled trial, indoor mosquito abundance was assessed in 110 star homes and 110 neighbouring traditional houses in 59 villages from Jan 5, 2022, to Dec 20, 2023. Mosquitoes were collected using US Centers for Disease Control light traps every 7 weeks. Anopheles gambiae and Anopheles funestus species were identified using PCR and Plasmodium falciparum sporozoites detected using ELISA. Nightly temperature, CO2 concentrations, and duration of door opening was recorded. Differences between study groups were analysed using generalised linear mixed-effects models. The trial is registered with ClinicalTrials.gov (NCT04529434).

FINDINGS

Of 9290 mosquitoes collected, 1899 were A gambiae, 69 were A funestus, and 7322 Culex species, mainly Culex quinquefasciatus. Star homes had 51% less A gambiae (adjusted risk ratio [RR] 0·49, 95% CI 0·35 to 0·69; p<0·0001) and 61% less Culex species (RR 0·39, 0·32 to 0·48; p<0·0001) than traditional houses. At night, star homes were 0·5°C cooler (95% CI 0·2 to 0·9; p=0·010), with similar concentrations of CO2 (-7 ppm, 95% CI -19 to 6; p=0·285) and had external doors open 53% less time than traditional houses (7·5 min/h vs 16·2 min/h; p<0·0001).

INTERPRETATION

Star homes reduced indoor mosquito abundance and malaria transmission risk compared with traditional houses, demonstrating the protective efficacy of houses that are well screened and air permeable in rural Africa.

FUNDING

Hanako Foundation, Singapore.

Review on the impacts of indoor vector control on domiciliary pests: good intentions challenged by harsh realities

Arthropod vectored diseases have been a major impediment to societal advancements globally. Strategies to mitigate transmission of these diseases include preventative care (e.g. vaccination), primary treatment and most notably, the suppression of vectors in both indoor and outdoor spaces. The outcomes of indoor vector control (IVC) strategies, such as long-lasting insecticide-treated nets (LLINs) and indoor residual sprays (IRSs), are heavily influenced by individual and community-level perceptions and acceptance. These perceptions, and therefore product acceptance, are largely influenced by the successful suppression of non-target nuisance pests such as bed bugs and cockroaches. Adoption and consistent use of LLINs and IRS is responsible for immense reductions in the prevalence and incidence of malaria. However, recent observations suggest that failed control of indoor pests, leading to product distrust and abandonment, may threaten vector control programme success and further derail already slowed progress towards malaria elimination. We review the evidence of the relationship between IVC and nuisance pests and discuss the dearth of research on this relationship. We make the case that the ancillary control of indoor nuisance and public health pests needs to be considered in the development and implementation of new technologies for malaria elimination.

Why using bed nets is a challenge among minority populations in Central Vietnam

BACKGROUND

Despite freely distributed insecticide-treated nets (ITNs) and health information campaigns to increase their use among populations at risk, malaria transmission persists in forested areas in Vietnam, especially among ethnic minority communities. A mixed-methods study was conducted in four villages of Ca Dong and M'nong ethnicity in Central Vietnam between 2009 and 2011 to assess factors limiting the uptake of ITNs.

METHODS

The mixed-methods research design consisted of a qualitative study to explore the context and barriers to ITN use, and a cross-sectional household survey (n = 141) to quantify factors for limited and appropriate net use.

RESULTS

The Ca Dong and M'nong's livelihood was dependent on swidden farming in the forest. Poverty-related factors, including the lack of beds, blankets, the practice of sleeping around the kitchen fire and deteriorated ITNs due to open housing structures, were reasons for alternative and non-use of ITNs. When household members stayed overnight in plot huts at fields, ITNs were even more unavailable and easily deteriorated. 72.5% of households reported having received one net for every two persons, and 82.2% of participants reported to have used ITNs the night before the survey. However, only 18.4% of participants were estimated to be effectively protected by ITNs after accounting for the availability of torn ITNs and the way ITNs were used, for example as blankets, at both village and fields. Multi-variable logistic regression showed the effect of four significant factors for appropriate ITN use: i) being female (AOR = 8.08; p = 0.009); ii) aware of mosquito bites as the sole cause of malaria (AOR = 7.43; p = 0.008); iii) not sleeping around the kitchen fire (AOR = 24.57; p = 0.001); and iv) having sufficient number of ITNs in the household (AOR = 21.69; p = 0.001).

CONCLUSION

This study showed how social factors rooted in poverty and swidden agriculture limited the effective use of ITNs, despite high coverage, among ethnic minority populations in Central Vietnam. An in-depth understanding of the local context is essential to develop specific indicators for measuring ITN use.

OUP accepted manuscript

BACKGROUND

Insecticide-treated net (ITN) use is among the most recommended strategies to prevent malaria in pregnancy. We analysed the regional and socio-economic patterns of ITN use among pregnant women in Kenya using data from the 2003, 2008 and 2014 Kenyan Demographic and Health Surveys (KDHSs).

METHODS

Inequality was assessed using four dimensions: economic status, education, place of residence and region. Both relative and absolute summary measures were applied. In addition, simple and complex summary measures, i.e. difference, population attributable fraction, population attributable risk and ratio were considered based on the number of subgroups in each variable.

RESULTS

There was overt inequality in the use of ITNs among pregnant women, with greater use among the better-off group in 2003 and 2014. Greater ITN use was also observed among pregnant women with a higher level of education. Pregnant women from urban settings tended to use ITNs (slept under a net the night before the survey) more than their rural counterparts in the 2003 KDHS. There were significant regional variations across the three surveys in all inequality summary measures, except ratio in the 2014 survey.

CONCLUSIONS

Significant inequality in ITN use among pregnant women was observed at a macro scale.

Field efficacy of ethnomedicinal plant smoke repellency against Anopheles arabiensis and Aedes aegypti

The repellency effect of smoke from burning Azadirachta indica, Eucalyptus camaldulensis and Ocimum forskolin plants to reduce human-mosquito biting activity. Ground mixed powders of the plant leaves produced smoke by direct burning and thermal expulsion on the traditional stoves in experimental huts against An. arabiensis and Ae. aegypti. A four-by-four Latin-square design was used to assign treatment and control experimental huts over different nights. In the treatment huts, the percent repellency of the smoke produced by burning powdered plant mixtures of the plants were determined by reduction mosquito density. There was a reduction on An. arabiensis (93.75%, P < 0.001) and Ae. aegypti (92%, P < 0.001) respectively, for huts with burning powder versus no treatment. Overall, plant mixed powders tested by both methods of application offered significant protection (>90%) against both mosquito species tested and has the potential to be used as an alternative mosquito control method.

Improved housing versus usual practice for additional protection against clinical malaria in The Gambia (RooPfs): a household-randomised controlled trial

BACKGROUND

In malaria-endemic areas, residents of modern houses have less malaria than those living in traditional houses. We aimed to assess whether children in The Gambia received an incremental benefit from improved housing, where current best practice of insecticide-treated nets, indoor residual spraying, seasonal malaria chemoprevention in children younger than 5 years, and prompt treatment against clinical malaria was in place.

METHODS

In this randomised controlled study, 800 households with traditional thatched-roofed houses were randomly selected from 91 villages in the Upper River Region of The Gambia. Within each village, equal numbers of houses were randomly allocated to the control and intervention groups using a sampling frame. Houses in the intervention group were modified with metal roofs and screened doors and windows, whereas houses in the control group received no modifications. In each group, clinical malaria in children aged 6 months to 13 years was monitored by active case detection over 2 years (2016-17). We did monthly collections from indoor light traps to estimate vector densities. Primary endpoints were the incidence of clinical malaria in study children with more than 50% of observations each year and household vector density. The trial is registered at ISRCTN02622179.

FINDINGS

In June, 2016, 785 houses had one child each recruited into the study (398 in unmodified houses and 402 in modified houses). 26 children in unmodified houses and 28 children in modified houses did not have at least 50% of visits in a year and so were excluded from analysis. 38 children in unmodified houses were recruited after study commencement, as were 21 children in modified houses, meaning 410 children in unmodified houses and 395 in modified houses were included in the parasitological analyses. At the end of the study, 659 (94%) of 702 children were reported to have slept under an insecticide-treated net; 662 (88%) of 755 children lived in houses that received indoor residual spraying; and 151 (90%) of 168 children younger than 5 years had seasonal malaria chemoprevention. Incidence of clinical malaria was 0·12 episodes per child-year in children in the unmodified houses and 0·20 episodes per child-year in the modified houses (unadjusted incidence rate ratio [RR] 1·68 [95% CI 1·11-2·55], p=0·014). Household vector density was 3·30 Anopheles gambiae per house per night in the unmodified houses compared with 3·60 in modified houses (unadjusted RR 1·28 [0·87-1·89], p=0·21).

INTERPRETATION

Improved housing did not provide protection against clinical malaria in this area of low seasonal transmission with high coverage of insecticide-treated nets, indoor residual spraying, and seasonal malaria chemoprevention.

FUNDING

Global Health Trials funded by Medical Research Council, UK Department for International Development, and Wellcome Trust.

Influence of house characteristics on mosquito distribution and malaria transmission in the city of Yaoundé, Cameroon

Background

Improving house structure is known to limit contact between humans and mosquitoes and reduce malaria transmission risk. In the present study, the influence of house characteristics on mosquito distribution and malaria transmission risk was assessed in the city of Yaoundé.

Methods

The study was conducted from March 2017 to June 2018 in 32 districts of the city of Yaoundé. Mosquito collections were performed indoor in 10 to 15 houses per district using CDC light traps. A total of 467 houses, selected randomly were used. A pretested questionnaire was submitted to participants of the study to collect information on the household: the number of people per house, education level, type of walls, presence of ceilings and eaves, number of windows, usage of long-lasting insecticidal nets (LLINs), number of bedroom and number of window. Mosquitoes collected were identified morphologically. Anophelines were tested by ELISA to detect infection by Plasmodium parasites. General Estimating Equations adjusting for repeated measures in the same house fitting negative binomial analysis were used to assess the influence of house characteristics on mosquito distribution.

Results

A total of 168,039 mosquitoes were collected; Culex spp emerged as the predominant species (96.48%), followed by Anopheles gambiae sensu lato (s.l.) (2.49%). Out of the 1033 An. gambiae s.l. identified by PCR, 90.03% were Anopheles coluzzii and the remaining were An. gambiae sensu stricto (s.s.) (9.97%). The high number of people per household, the presence of screens on window and the possession of LLINs were all associated with fewer mosquitoes collected indoors, whilst opened eaves, the high number of windows, the presence of holes in walls and living close to breeding sites were associated with high densities of mosquitoes indoor. Out of 3557 Anophelines tested using ELISA CSP, 80 were found infected by Plasmodium falciparum parasites. The proportion of mosquitoes infected did not vary significantly according to house characteristics.

Conclusion

The study indicated that several house characteristics such as, the presence of holes on walls, opened eaves, unscreened window and living close to breeding sites, favored mosquito presence in houses. Promoting frequent use of LLINs and house improvement measures, such as the use of screen on windows, closing eaves, cleaning the nearby environment, should be integrated in strategies to improve malaria control in the city of Yaoundé.

Effect of user preferences on ITN use: a review of literature and data

Background

Insecticide-treated bed nets (ITNs) are the primary tool for vector control, and optimizing ITN use is a key concern of national programmes. Available evidence indicates that bed net users often have preferences for shape, colour, size, and other attributes, but it is unclear whether these preferences are strong enough to have any significant effect on bed net use, and whether countries and donors should invest in more expensive attributes in order to maximize ITN use. The link between bed net attributes, preferences, and use was investigated using a literature review and review of publicly available, nationally representative household surveys from sub-Saharan Africa.

Methods

A literature search was conducted to identify publications with data on preferences for net attributes and on associations between net attributes and use. Publicly available DHS and MIS datasets were screened for variables on net preferences and net attributes. Wald tests were run to obtain odds ratios and confidence intervals for the use of nets of various attributes in univariate analysis. A multilevel logistic regression was constructed to assess the odds of a net’s use, controlling for background variables and adding random effects variables at the household and cluster level.

Results

Preferences for certain net attributes exist, but do not impede high rates of net use in countries where data were available. Stated preferences for shape and colour do not significantly influence net use to degrees that would require action by programme planners. By and large, people are using the nets they receive, and when they do not, it is for reasons unrelated to shape and size (primarily perceived mosquito density, heat or an excess of nets). Households in higher wealth quintiles tend to own greater numbers of conical nets, indicating that they have the ability to obtain or purchase these nets on their own, and individuals resident in higher wealth quintile households also use conical nets preferentially.

Conclusions

The increased manufacturing costs for conical nets are not outweighed by the very small, often non-existent, increases in use rates in sub-Saharan Africa. Programmes that wish to explore the relationship between net attributes, preferences and use rates should include these questions in nationally representative household surveys to be able to capture trends across geographic and socio-economic groups.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-017-1879-8) contains supplementary material, which is available to authorized users.

Determinants of Bed Net Use in Southeast Nigeria following Mass Distribution of LLINs: Implications for Social Behavior Change Interventions

Millions of long-lasting insecticide treated nets (LLINs) have been distributed as part of the global malaria control strategy. LLIN ownership, however, does not necessarily guarantee use. Thus, even in the ideal setting in which universal coverage with LLINs has been achieved, maximal malaria protection will only be achieved if LLINs are used both correctly and consistently. This study investigated the factors associated with net use, independent of net ownership. Data were collected during a household survey conducted in Ebonyi State in southeastern Nigeria in November 2011 following a statewide mass LLIN distribution campaign and, in select locations, a community-based social behavior change (SBC) intervention. Logistic regression analyses, controlling for household bed net ownership, were conducted to examine the association between individual net use and various demographic, environmental, behavioral and social factors. The odds of net use increased among individuals who were exposed to tailored SBC in the context of a home visit (OR = 17.11; 95% CI 4.45-65.79) or who received greater degrees of social support from friends and family (ptrend < 0.001). Factors associated with decreased odds of net use included: increasing education level (ptrend = 0.020), increasing malaria knowledge level (ptrend = 0.022), and reporting any disadvantage of bed nets (OR = 0.39; 95% CI 0.23-0.78). The findings suggest that LLIN use is significantly influenced by social support and exposure to a malaria-related SBC home visit. The malaria community should thus further consider the importance of community outreach, interpersonal communication and social support on adoption of net use behaviors when designing future research and interventions.

Mass drug administration for malaria

BACKGROUND

Mass drug administration (MDA), defined as the empiric administration of a therapeutic antimalarial regimen to an entire population at the same time, has been a historic component of many malaria control and elimination programmes, but is not currently recommended. With renewed interest in MDA and its role in malaria elimination, this review aims to summarize the findings from existing research studies and program experiences of MDA strategies for reducing malaria burden and transmission.

OBJECTIVES

To assess the impact of antimalarial MDA on population asexual parasitaemia prevalence, parasitaemia incidence, gametocytaemia prevalence, anaemia prevalence, mortality and MDA-associated adverse events.

SEARCH METHODS

We searched the Cochrane Infectious Disease Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE+, EMBASE, to February 2013. We also searched CABS Abstracts, LILACS, reference lists, and recent conference proceedings.

SELECTION CRITERIA

Cluster-randomized trials and non-randomized controlled studies comparing therapeutic MDA versus placebo or no MDA, and uncontrolled before-and-after studies comparing post-MDA to baseline data were selected. Studies administering intermittent preventive treatment (IPT) to sub-populations (for example, pregnant women, children or infants) were excluded.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed studies for inclusion, extracted data and assessed risk of bias. Studies were stratified by study design and then subgrouped by endemicity, by co-administration of 8-aminoquinoline plus schizonticide drugs and by plasmodium species. The quality of evidence was assessed using the GRADE approach.

MAIN RESULTS

Two cluster-randomized trials, eight non-randomized controlled studies and 22 uncontrolled before-and-after studies are included in this review. Twenty-two studies (29 comparisons) compared MDA to placebo or no intervention of which two comparisons were conducted in areas of low endemicity (≤5%), 12 in areas of moderate endemicity (6-39%) and 15 in areas of high endemicity (≥ 40%). Ten studies evaluated MDA plus other vector control measures. The studies used a wide variety of MDA regimens incorporating different drugs, dosages, timings and numbers of MDA rounds. Many of the studies are now more than 30 years old. Areas of low endemicity (≤5%)Within the first month post-MDA, a single uncontrolled before-and-after study conducted in 1955 on a small Taiwanese island reported a much lower prevalence of parasitaemia following a single course of chloroquine compared to baseline (1 study, very low quality evidence). This lower parasite prevalence was still present after more than 12 months (one study, very low quality evidence). In addition, one cluster-randomized trial evaluating MDA in a low endemic setting reported zero episodes of parasitaemia at baseline, and throughout five months of follow-up in both the control and intervention arms (one study, very low quality evidence). Areas of moderate endemicity (6-39%)Within the first month post-MDA, the prevalence of parasitaemia was much lower in three non-randomized controlled studies from Kenya and India in the 1950s (RR 0.03, 95% CI 0.01 to 0.08, three studies, moderate quality evidence), and in three uncontrolled before-and-after studies conducted between 1954 and 1961 (RR 0.29, 95% CI 0.17 to 0.48, three studies,low quality evidence).The longest follow-up in these settings was four to six months. At this time point, the prevalence of parasitaemia remained substantially lower than controls in the two non-randomized controlled studies (RR 0.18, 95% CI 0.10 to 0.33, two studies, low quality evidence). In contrast, the two uncontrolled before-and-after studies found mixed results: one found no difference and one found a substantially higher prevalence compared to baseline (not pooled, two studies, very low quality evidence). Areas of high endemicity (≥40%)Within the first month post-MDA, the single cluster-randomized trial from the Gambia in 1999 found no significant difference in parasite prevalence (one study, low quality evidence). However, prevalence was much lower during the MDA programmes in three non-randomized controlled studies conducted in the 1960s and 1970s (RR 0.17, 95% CI 0.11 to 0.27, three studies, moderate quality evidence), and within one month of MDA in four uncontrolled before-and-after studies (RR 0.37, 95% CI 0.28 to 0.49, four studies,low quality evidence).Four trials reported changes in prevalence beyond three months. In the Gambia, the single cluster-randomized trial found no difference at five months (one trial, moderate quality evidence). The three uncontrolled before-and-after studies had mixed findings with large studies from Palestine and Cambodia showing sustained reductions at four months and 12 months, respectively, and a small study from Malaysia showing no difference after four to six months of follow-up (three studies,low quality evidence). 8-aminoquinolines We found no studies directly comparing MDA regimens that included 8-aminoquinolines with regimens that did not. In a crude subgroup analysis with a limited number of studies, we were unable to detect any evidence of additional benefit of primaquine in moderate- and high-transmission settings. Plasmodium species In studies that reported species-specific outcomes, the same interventions resulted in a larger impact on Plasmodium falciparum compared to P. vivax.

AUTHORS' CONCLUSIONS

MDA appears to reduce substantially the initial risk of malaria parasitaemia. However, few studies showed sustained impact beyond six months post-MDA, and those that did were conducted on small islands or in highland settings.To assess whether there is an impact of MDA on malaria transmission in the longer term requires more quasi experimental studies with the intention of elimination, especially in low- and moderate-transmission settings. These studies need to address any long-term outcomes, any potential barriers for community uptake, and contribution to the development of drug resistance.

Family biosocial variables influencing the use of insecticide treated nets for children in Eastern Nigeria

Background:

Effective reduction of malaria morbidity and mortality in Nigerian children under the age of five depends to a large extent on family biosocial factors. Although, the awareness of insecticide treated bed nets (ITNs) is reportedly high and increasing in Nigeria there remain large gaps between awareness, possession and use by families with children under the age of five in Nigeria.

Aim:

To determine the family biosocial variables that influence the use of insecticide treated nets for children in Eastern Nigeria.

Materials and Methods:

A descriptive hospital-based study was carried out from June 2008-June 2011 on a cross-section of 415 mothers with children under the age of five, who were treated for confirmed malaria, and met the selection criteria were interviewed using a pretested, structured researcher-administered questionnaire. The questionnaire tool elicited information on family socio-demographic variables, inter-spousal discussion, communication, concurrence and participation in the use of insecticide treated bed nets; and reasons for non-utilization. The period of usage in the previous 6 months was assessed and graded using a scoring system of 0-4. Scores of 1-4 indicated usage while score of 0 meant non use.

Results:

The rate of ITNs use was 53.0%. The family variables that significantly influenced utilization were secondary education and above of parents (mother: P = 0.009; father: P = 0.001), monogamy (P value = 0.024), family size of 1-4 (P value = 0.016) and parents living together (P = 0.001); others included parents’ occupation (mother: P = 0.003; father: P = 0.04) and inter-spousal discussion (P value = 0.001), communication (P value = 0.001), concurrence (P = 0.000) and participation (P = 0.000). The commonest reason for non- use was inconvenience during sleep (P = 0.04).

Conclusion:

This study shows that the rate of ITN use was marginally good. Specifically, this rate was significantly influenced by some family variables. The families of children under the age of five should, therefore, be the focus of intensive health promotion campaign to influence the use of ITNs to produce ITN family friendly communities.

Determinants of long-lasting insecticidal net use in Burkina Faso after a mass distribution in the Diébougou health district

BACKGROUND

In 2009, a mass distribution of long-lasting insecticidal nets (LLINs) was conducted in an experimental site of the Diébougou health district. Carried out 1year after the distribution, this study aimed to determine the presence of LLINs in households, to determine the LLIN use rate, and thirdly, to identify key factors associated with LLIN use in households.

METHODS

We conducted a cross-sectional descriptive and analytical study, which covered the entire Diébougou health district. The study population consisted of households in the district. The statistical unit was the household head, or if absent his designated representative. For the selection of households to be studied, we considered the health centers and their geographic accessibility. We thus defined three zones: an area within 5 km of health centers, the area between 5 and 10 km away, and the area beyond 10 km. In each area, we randomly selected 20 households, totaling 60 households in the area of each health center, giving a sample of 840 households to be surveyed. We selected 60 households per health center in accordance with the time and financial resources allocated to data collection. The data were analyzed using the Epi Info 3.5.1 software package. The Chi square test was used to investigate the association between the dependent and independent variables with statistical significance set at P<0.05. When an association was demonstrated, the relative risk (RR) was calculated with the 95% confidence interval.

RESULTS

A total of 822 households (97.8%) were surveyed, households inhabited by 6379 people including 1175 (11.4%) children under 5 years of age and 158 (2.5%) pregnant women. The overall use of LLINs was 76.5%. This rate was 81.7% in children under 5 years and 57.6% among pregnant women. Factors influencing the use of LLINs were the implementation of a communication plan by health actors (RR=2.42 [2.03-2.83]), the social position of the household head (RR=1.62 [1.43-1.83]), the marital status of the household head (RR=1.41 [1.33-1.49]), the number of persons per room (RR=1.39 [1.08-1.78]), the religion of household head (RR=1.21 [1.15-1.27]), the level of education of the household head (RR=1.15 [1.06-1.24]), and the number of IECs (information, education, communication) sessions followed by the household (RR=1.14 [1.08-1.20]).

CONCLUSION

The results of this study provide guidance on measures to ensure the success of the mass distribution of LLINs to the entire country.

Social and behavioural baseline for guiding implementation of an efficacy trial of insecticide impregnated bed nets for malaria control at nsukka, Nigeria

Insecticide impregnated bed nets are being tested in many tropical areas as a major tool to control malaria. In a few African countries, there is a history of local bed net production and use, while in most others, ownership of commercially-produced nets is rare due to high costs relative to local income. Such variations in pre-existing bed net use behavior must be studied prior to designing new intervention trials. A "baseline" diagnostic study in Nsukka Local Government of Enugu State, Nigeria, found that local beliefs about malaria causation, which include heat from the sun and hard work, may reduce the perceived efficacy of bed nets as an appropriate malaria control action. While the belief that mosquitos can cause malaria increased with level of formal education, the study also documented that educated people simultaneously hold both indigenous and scientific perceptions about malaria. Although the project provided bed nets, curtains and residual house spray for free, long-term sustainability may be influenced by the main constraint to current ownership of a bed net, i.e., cost. Issues, such as concern about feeling hot under the nets, a tendency to sleep outside during the hot dry season, and variations in people's ideas about what constitutes a malaria episode, point to the need to monitor the bed net intervention. This is recommended as a means of learning how people perceive the efficacy of the nets, whether they use them correctly and whether the intervention can be sustained and integrated into local primary health care programs.

A socio-ecological assessment aiming at improved forest resource management and sustainable ecotourism development in the mangroves of Tanbi Wetland National Park, The Gambia, West Africa

Although mangroves dominated by Avicennia germinans and Rhizophora mangle are extending over 6000 ha in the Tanbi Wetland National Park (TWNP) (The Gambia), their importance for local populations (both peri-urban and urban) is not well documented. For the first time, this study evaluates the different mangrove resources in and around Banjul (i.e., timber, non-timber, edible, and ethnomedicinal products) and their utilization patterns, including the possibility of ecotourism development. The questionnaire-based results have indicated that more than 80% of peri-urban population rely on mangroves for timber and non-timber products and consider them as very important for their livelihoods. However, at the same time, urban households demonstrate limited knowledge on mangrove species and their ecological/economic benefits. Among others, fishing (including the oyster-Crassostrea cf. gasar collection) and tourism are the major income-generating activities found in the TWNP. The age-old practices of agriculture in some parts of the TWNP are due to scarcity of land available for agriculture, increased family size, and alternative sources of income. The recent focus on ecotourism (i.e., boardwalk construction inside the mangroves near Banjul city) received a positive response from the local stakeholders (i.e., users, government, and non-government organizations), with their appropriate roles in sharing the revenue, rights, and responsibilities of this project. Though the guidelines for conservation and management of the TWNP seem to be compatible, the harmony between local people and sustainable resource utilization should be ascertained.

Feasibility of home management using ACT for childhood malaria episodes in an urban setting

BACKGROUND

Over 90% of malaria cases occur in Sub-Saharan Africa, where a child under the age of 5 years dies from this illness every 30 seconds. The majority of families in Sub- Saharan Africa treat malaria at home, but therapy is often incomplete, hence the World Health Organization has adopted the strategy of home management of malaria to solve the problem. The purpose of this study was to determine community perception and the treatment response to episodes of childhood malaria in an urban setting prior to implementation of home management using artemisinin-based combination therapy (ACT).

METHODS

This qualitative exploratory study on the home management of malaria in urban children under 5 years of age used 15 focus group discussions and 20 in-depth interviews in various categories of caregivers of children under 5 years. One hundred and eighteen people participated in the focus group discussions and 20 in the in-depth interviews. The study explored beliefs and knowledge about malaria, mothers' perception of home management of the disease, health-seeking behavior, prepackaged treatment of malaria using ACT and a rapid diagnostic test, preferred channels for home management of uncomplicated malaria, communication, the role of the community in home management of malaria, and the motivation of drug distributors in the community.

RESULTS

The mothers' perception of malaria was the outcome of events other than mosquito bites. Home treatment is very common and is guided by the way mothers perceive signs and symptoms of malaria. Frequent change of malarial drugs by the national health policy and financial difficulties were the main problems mothers faced in treating febrile children. Rapid diagnostic testing and prepackaged ACT for simple malaria in children under 5 years would be accepted if it was offered at an affordable price. Tribalism and religious beliefs might hinder the delivery of home management of malaria. The availability of rapid diagnostic testing and ACT all year round is one of the challenges of home management of malaria. Although radio and television featured among the current sources of information within the community, meetings, churches, schools, and other public gatherings were the best venues for social mobilization, while community health workers and community leaders were the best sensitization agents for positive behavior change to adhere to home management of malaria. Monetary incentives should be offered to community drug distributors. This should be deducted from the combined price of ACT and rapid diagnostic testing.

CONCLUSION

For successful implementation of home management of malaria, there should be proper education, social mobilization of the population, and continuous monitoring and evaluation of field activities to ensure adequate stocks of ACT and rapid diagnostic testing within the framework of the intervention.

An exploratory survey of malaria prevalence and people's knowledge, attitudes and practices of mosquito larval source management for malaria control in western Kenya

A large proportion of mosquito larval habitats in urban and rural communities in sub-Saharan Africa are man-made. Therefore, community-based larval source management (LSM) could make a significant contribution to malaria control in an integrated vector management approach. Here we implemented an exploratory study to assess malaria prevalence and people's knowledge, attitudes and practices on malaria transmission, its control and the importance of man-made aquatic habitats for the development of disease vectors in one peri-urban lowland and two rural highland communities in western Kenya. We implemented monthly cross-sectional malaria surveys and administered a semi-structured questionnaire in 90 households, i.e. 30 households in each locality. Malaria prevalence was moderate (3.2-6.5%) in all sites. Nevertheless, residents perceived malaria as their major health risk. Thirty-two percent (29/90) of all respondents did not know that mosquitoes are responsible for the transmission of malaria. Over two-thirds (69/90) of the respondents said that mosquito breeding site could be found close to their homes but correct knowledge of habitat characteristics was poor. Over one-third (26/67) believed that immature mosquitoes develop in vegetation. Man-made pools, drainage channels and burrow pits were rarely mentioned. After explaining where mosquito larvae develop, 56% (50/90) felt that these sites were important for their livelihood. Peri-urban residents knew more about mosquitoes' role in malaria transmission, could more frequently describe the larval stages and their breeding habitats, and were more likely to use bed nets even though malaria prevalence was only half of what was found in the rural highland sites (p<0.05). This was independent of their education level or socio-economic status. Hence rural communities are more vulnerable to malaria infection, thus calling for additional methods to complement personal protection measures for vector control. Larval source management was the most frequently mentioned (30%) tool for malaria control but was only practiced by 2 out of 90 respondents. Targeting the larval stages of malaria vectors is an underutilized malaria prevention measure. Sustainable elimination or rendering of such habitats unsuitable for larval development needs horizontally organized, community-based programs that take people's needs into account. Innovative, community-based training programs need to be developed to increase people's awareness of man-made vector breeding sites and acceptable control methods need to be designed in collaboration with the communities.

Screening mosquito house entry points as a potential method for integrated control of endophagic filariasis, arbovirus and malaria vectors

Background

Partial mosquito-proofing of houses with screens and ceilings has the potential to reduce indoor densities of malaria mosquitoes. We wish to measure whether it will also reduce indoor densities of vectors of neglected tropical diseases.

Methodology

The main house entry points preferred by anopheline and culicine vectors were determined through controlled experiments using specially designed experimental huts and village houses in Lupiro village, southern Tanzania. The benefit of screening different entry points (eaves, windows and doors) using PVC-coated fibre glass netting material in terms of reduced indoor densities of mosquitoes was evaluated compared to the control.

Findings

23,027 mosquitoes were caught with CDC light traps; 77.9% (17,929) were Anopheles gambiae sensu lato, of which 66.2% were An. arabiensis and 33.8% An. gambiae sensu stricto. The remainder comprised 0.2% (50) An. funestus, 10.2% (2359) Culex spp. and 11.6% (2664) Mansonia spp. Screening eaves reduced densities of Anopheles gambiae s. l. (Relative ratio (RR)  = 0.91; 95% CI = 0.84, 0.98; P = 0.01); Mansonia africana (RR = 0.43; 95% CI = 0.26, 0.76; P<0.001) and Mansonia uniformis (RR = 0.37; 95% CI = 0.25, 0.56; P<0.001) but not Culex quinquefasciatus, Cx. univittatus or Cx. theileri. Numbers of these species were reduced by screening windows and doors but this was not significant.

Significance

This study confirms that across Africa, screening eaves protects households against important mosquito vectors of filariasis, Rift Valley Fever and O'Nyong nyong as well as malaria. While full house screening is required to exclude Culex species mosquitoes, screening of eaves alone or fitting ceilings has considerable potential for integrated control of other vectors of filariasis, arbovirus and malaria.

Mosquito vectors that transmit filariasis and several arboviruses such as Rift Valley Fever, Chikungunya and O'Nyong nyong as well as malaria co-occur across tropical Africa. These diseases are co-endemic in most rural African countries where they are transmitted by the same mosquito vectors. The only control measure currently in widespread use is mass drug administration for filariasis. In this study, we used controlled experiments to evaluate the benefit of screening the main mosquito entry points into houses, namely, eaves, windows and doors. This study aims to illustrate the potential of screening specific house openings with the intention of preventing endophagic mosquitoes from entering houses and thus reducing contact between humans and vectors of neglected tropical diseases. This study confirms that while full house screening is effective for reducing indoor densities of Culex spp. mosquitoes, screening of eaves alone has a great potential for integrated control of neglected tropical diseases and malaria.

Determinants of bednet ownership and use in visceral leishmaniasis-endemic areas of the Indian subcontinent

OBJECTIVE

To document ownership and use of bednets with its determinants in the visceral leishmaniasis (VL)-endemic region where mainly non-insecticide impregnated nets are available through commercial channels, and bednets are being considered as a leishmaniasis vector control measure.

METHODS

In August-September 2006, semi-structured household (HH) questionnaires and observation guides were used in a random sample of 1330 HHs in VL-endemic districts of India and Nepal to collect data on VL knowledge, HH socio-economic status, bednet ownership and use patterns. An asset index was constructed to allow wealth ranking of the HH. A binary logistic response General Estimating Equations model was fitted to evaluate the determinants of bednet ownership and use.

RESULTS

The proportion of HHs with at least one bednet purchased on the commercial market was 81.5% in India and 70.2% in Nepal. The bednets were used in all seasons by 50.6% and 54.1% of the Indian and Nepalese HH owning a bed net. There was striking inequity in bednet ownership: only 38.3% of the poorest quintile in Nepal owned at least one net, compared to 89.7% of the wealthiest quintile. In India, the same trend was observed though somewhat less pronounced (73.6%vs. 93.7%). Multivariate analysis showed that poverty was an important independent predictor for not having a bednet in the HH [OR 5.39 (2.90-10.03)].

CONCLUSION

Given the inequity in commercial bednet ownership, free distribution of insecticide-treated bednets to the general population seems imperative to achieve a mass effect on vector density.

Acceptability, willing to purchase and use long lasting insecticide treated mosquito nets in Orissa State, India

Long lasting insecticide treated nets (LLINs) that require no re-treatment have been advocated as an effective tool against malaria transmission. However, success of this community based intervention measure largely depends on its acceptability and proper usage by the target population, besides assuring access to bed nets. To determine the acceptability of LLIN, its usage and people's willingness to buy the net, a study was conducted in two tribal districts viz., Malkangiri (with ongoing ITN programme) and Koraput (no ITN programme) of Orissa State, India. Both qualitative and quantitative data collection methods were used to collect information regarding the objective of the study. A total of 2457 LLINs (Olyset Nets) were distributed in the selected villages of these districts at free of cost. In the study villages of Malkangiri, 58% of the households had either ITNs (73%) or other types of mosquito nets aside from the LLINs and in the villages of Koraput, only 8% had other nets, as majority (96%) informed that buying nets from market was not affordable to them. Physical verification of the nets during the house visits revealed that 75.4% and 83% (in ITNs and non-ITNs villages, respectively) of the LLINs and 76% of the other nets (including ITNs) were used by the respondents, the night before the survey as nets were in a hanging position at the time of the visit. Majority of the respondents (76-98%) felt that reduction of mosquito bites as the main perceived benefit of using the LLINs. About 55% and 67% of the respondents from non-ITNs and ITNs areas, respectively, expressed their willingness to buy the LLINs. Among them, 76.8% and 94.7% offered to pay INR<100 for a net and also ready to buy it by cash payment. Social marketing of LLINs at a subsidized price or free supply to the deserving sections of people (socially/economically poor and/or under-privileged) and ensuring the availability of nets during harvesting season could encourage people to buy and use LLINs.

Decreased motivation in the use of insecticide-treated nets in a malaria endemic area in Burkina Faso

Background

The use of insecticide-treated nets (ITN) is an important tool in the Roll Back Malaria (RBM) strategy. For ITNs to be effective they need to be used correctly. Previous studies have shown that many factors, such as wealth, access to health care, education, ethnicity and gender, determine the ownership and use of ITNs. Some studies showed that free distribution and public awareness campaigns increased the rate of use. However, there have been no evaluations of the short- and long-term impact of such motivation campaigns. A study carried out in a malaria endemic area in south-western Burkina Faso indicated that this increased use declined after several months. The reasons were a combination of the community representation of malaria, the perception of the effectiveness and usefulness of ITNs and also the manner in which households are organized by day and by night.

Methods

PermaNet 2.0^® and Olyset^® were distributed in 455 compounds at the beginning of the rainy season. The community was educated on the effectiveness of nets in reducing malaria and on how to use them. To assess motivation, qualitative tools were used: one hundred people were interviewed, two hundred houses were observed directly and two houses were monitored monthly throughout one year.

Results

The motivation for the use of bednets decreased after less than a year. Inhabitants' conception of malaria and the inconvenience of using bednets in small houses were the major reasons. Acceptance that ITNs were useful in reducing malaria was moderated by the fact that mosquitoes were considered to be only one of several factors which caused malaria. The appropriate and routine use of ITNs was adversely affected by the functional organization of the houses, which changed as between day and night. Bednets were not used when the perceived benefits of reduction in mosquito nuisance and of malaria were considered not to be worth the inconvenience of daily use.

Conclusion

In order to bridge the gap between possession and use of bednets, concerted efforts are required to change behaviour by providing accurate information, most particularly by convincing people that mosquitoes are the only source of malaria, whilst recognising that there are other diseases with similar symptoms, caused in other ways. The medical message must underline the seriousness of malaria and the presence of the malaria vector in the dry season as well as the wet, in order to encourage the use of bednets whenever transmission can occur. Communities would benefit from impregnated bednets and other vector control measures being better adapted to their homes, thus reducing the inconvenience of their use.

House design modifications reduce indoor resting malaria vector densities in rice irrigation scheme area in western Kenya

Background

Simple modifications of typical rural house design can be an effective and relatively inexpensive method of reducing indoor mosquito vector densities and consequently decreasing malaria transmission. Public health scientists have shown the potential for house design to protect people against malaria, yet this type of intervention remains virtually ignored. A randomized-controlled study was, therefore, undertaken to determine the effects of this method of vector control on the density of indoor resting malaria vectors in a rice irrigation scheme area in lowlands of western Kenya.

Methods

Ten treatment houses were modified with ceilings of papyrus mats and insecticide-treated netting (ITN) and tested against ten control houses without papyrus ceilings. To determine densities of mosquitoes resting in homes, the pyrethrum spray method was used to simultaneously collect indoor resting malaria vectors in intervention and control houses. Each house was sampled a total of eight times over a period of four months, resulting in a total of 80 sampling efforts for each treatment. Community response to such intervention was investigated by discussions with residents.

Results

Papyrus mats ceiling modification reduced house entry by Anopheles gambiae s.l and Anopheles funestus densities by between 78–80% and 86% respectively compared to unmodified houses. Geometric mean density of Anopheles gambiae s.l. and Anopheles funestus in modified houses were significantly lower (t₁₈ = 7.174, P < 0.0001 and t₁₈ = 2.52, P = 0.02, respectively) compared to controls. Unmodified houses were associated with relatively higher densities of malaria vectors. There was a 84% (OR 0.16, 95% CI 0.07–0.39, P < 0.0001) and 87% (OR 0.13, 95% CI 0.03–0.5, P = 0.0004) reduction in the odds of Anopheles gambiae s.l. and Anopheles funestus presence in modified houses, respectively, compared with unmodified houses. Residents responded favourably to this mode of vector control.

Conclusion

House modifications involving insect screen ceilings made from locally available materials and small ITN incorporated in house construction have the potential to reduce human exposure to malaria vectors, and thus parasite infection, in a rice irrigation scheme area of western Kenya. Ceiling modification is likely to be acceptable and is expected to be of greatest benefit when used in combination with other malaria control strategies.

Malaria prevention in north-eastern Tanzania: patterns of expenditure and determinants of demand at the household level

Objective

This study aims to provide a better understanding of the amounts spent on different malaria prevention products and the determinants of these expenditures.

Methods

1,601 households were interviewed about their expenditure on malaria mosquito nets in the past five years, net re-treatments in the past six months and other expenditures prevention in the past two weeks. Simple random sampling was used to select villages and streets while convenience sampling was used to select households. Expenditure was compared across bed nets, aerosols, coils, indoor spraying, using smoke, drinking herbs and cleaning outside environment.

Findings

68% of households owned at least one bed net and 27% had treated their nets in the past six months. 29% were unable to afford a net. Every fortnight, households spent an average of US $0.18 on nets and their treatment, constituting about 47% of total prevention expenditure. Sprays, repellents and coils made up 50% of total fortnightly expenditure (US$0.21). Factors positively related to expenditure were household wealth, years of education of household head, household head being married and rainy season. Poor quality roads and living in a rural area had a negative impact on expenditure.

Conclusion

Expenditure on bed nets and on alternative malaria prevention products was comparable. Poor households living in rural areas spend significantly less on all forms of malaria prevention compared to their richer counterparts. Breaking the cycle between malaria and poverty is one of the biggest challenges facing malaria control programmes in Africa.

Utilization of insecticide-treated nets by under-five children in Nigeria: assessing progress towards the Abuja targets

BACKGROUND

The Abuja target of increasing the proportion of people sleeping under insecticide-treated nets (ITNs) to 60% by the year 2005, as one of the measures for malaria control in Africa, has generated an influx of resources for malaria control in several countries in the region. A national household survey conducted in 2005 by the Malaria Control Programme in Nigeria assessed the progress made with respect to ITN ownership and use among pregnant women and children under five years of age since 2000. The survey was the first nationally representative study of ITN use assessing progress towards the Abuja target amongst vulnerable groups.

POPULATION AND METHOD

A cross-sectional survey of a sample of 7,200 households, selected by a multistage stratified sampling technique from 12 randomly selected states from the six geopolitical zones of the country. Data collection was done during the malarious rainy season (October 2005) using a modified WHO Malaria Indicator Survey structured questionnaire about household ownership and utilization of mosquito nets (treated or untreated) from household heads.

RESULTS

Household ownership of any net was 23.9% (95% CI, 22.8%-25.1%) and 10.1% for ITNs (95% CI, 9.2%-10.9%). Education, wealth index, presence of an under-five child in the household, family size, residence, and region by residence were predictive of ownership of any net. The presence of an under-five child in the household, family size, education, presence of health facility in the community, gender of household head, region by residence and wealth index by education predicted ITN ownership. Utilization of any net by children under-five was 11.5% (95% CI, 10.4%-12.6%) and 1.7% (95% CI, 1.3%-2.2%) for ITN. Predictors of use of any net among under-five children were fever in the previous two weeks, presence of health facility in the community, caregiver's education, residence, and wealth index by caregiver's education; while religion, presence of health facility and wealth index by caregiver's education predicted the use of ITN among this group.

CONCLUSION

This study demonstrated that the substantial increase in ITN utilization among children under five years of age in Nigeria is still far from the Abuja targets.

Mosquito abundance, bed net coverage and other factors associated with variations in sporozoite infectivity rates in four villages of rural Tanzania

Background

Entomological surveys are of great importance in decision-making processes regarding malaria control strategies because they help to identify associations between vector abundance both species-specific ecology and disease intervention factors associated with malaria transmission. Sporozoite infectivity rates, mosquito host blood meal source, bed net coverage and mosquito abundance were assessed in this study.

Methodology

A longitudinal survey was conducted in four villages in two regions of Tanzania. Malaria vectors were sampled using the CDC light trap and pyrethrum spray catch methods. In each village, ten paired houses were selected for mosquitoes sampling. Sampling was done in fortnight case and study was undertaken for six months in both Kilimanjaro (Northern Tanzania) and Dodoma (Central Tanzania) regions.

Results

A total of 6,883 mosquitoes were collected including: 5,628 (81.8%) Anopheles arabiensis, 1,100 (15.9%) Culex quinquefasciatus, 89 (1.4%) Anopheles funestus, and 66 (0.9%) Anopheles gambiae s.s. Of the total mosquitoes collected 3,861 were captured by CDC light trap and 3,022 by the pyrethrum spray catch method. The overall light trap: spray catch ratio was 1.3:1. Mosquito densities per room were 96.5 and 75.5 for light trap and pyrethrum spray catch respectively. Mosquito infectivity rates between villages that have high proportion of bed net owners and those without bed nets was significant (P < 0.001) and there was a significant difference in sporozoite rates between households with and without bed nets in these four villages (P < 0.001).

Conclusion

Malaria remains a major problem in the study areas characterized as low transmission sites. Further studies are required to establish the annual entomological inoculation rates and to observe the annual parasitaemia dynamics in these communities. Outdoor mosquitoes collection should also be considered.

The role of communication between clients and health care providers: implications for adherence to malaria treatment in rural Gambia

OBJECTIVES

One of the major barriers to the successful treatment of malaria is the non-adherence to drug regimens. Work till now has often been based on the assumption that most patients begin their treatment having received adequate or at least similar instructions and information about both the disease itself and the content and course of their treatment. This paper questions such an assumption. We ask whether people do not adhere to treatment in part because they have not understood the diagnosis and subsequent treatment from the outset.

METHODS

This study was conducted in the North Bank district of The Gambia, West Africa where a convenience sample of 1337 caretakers with children under 10 years of age were interviewed immediately after their consultation about their recommended treatment.

RESULTS

Findings show a mismatch between caretakers and healthcare providers' (HCP) interpretations of a child's clinic visit, both in terms of the diagnosis and drug regimen. Less than a third of the caretakers' responses matched the diagnosis that the HCP had written on the child's medical card. Results also showed a delay in the first important antimalarial dose. A common response was 'I'm not sure what is wrong with the child but I will start the medicine when I get home'.

CONCLUSIONS

The findings from these exit interviews lend weight to the argument that the value of pre-packaged blisters could potentially provide far greater benefits than their additional cost, especially when coupled with improved communication by HCP.

Recognition, perceptions and treatment practices for severe malaria in rural Tanzania: implications for accessing rectal artesunate as a pre-referral

OBJECTIVES

Preparatory to a community trial investigating how best to deliver rectal artesunate as pre-referral treatment for severe malaria; local understanding, perceptions of signs/symptoms of severe malaria and treatment-seeking patterns for and barriers to seeking biomedical treatment were investigated.

METHODOLOGY/PRINCIPAL FINDINGS

19 key informant interviews, 12 in-depth interviews and 14 focus group discussions targeting care-givers, opinion leaders, and formal and informal health care providers were conducted. Monthly fever episodes and danger signs or symptoms associated with severe malaria among under-fives were recorded. Respondents recognized convulsions, altered consciousness and coma, and were aware of their risks if not treated. But, these symptoms were perceived to be caused by supernatural forces, and traditional healers were identified as primary care providers. With some delay, mothers eventually visited a health facility when convulsions were part of the illness, despite pressures against this. Although vomiting and failure to eat/suck/drink were associated with malaria, they were not considered as indicators of danger signs unless combined with another more severe symptom. Study communities were familiar with rectal application of medicines.

CONCLUSIONS/SIGNIFICANCE

Communities' recognition and awareness of major symptoms of severe malaria could encourage action, but perceptions of their causes and poor discrimination of other danger signs - vomiting and failure to feed - might impede early treatment. An effective health education targeting parents/guardians, decision-makers/advisors, and formal and informal care providers might be a prerequisite for successful introduction of rectal artemisinins as an emergency treatment. Role of traditional healers in delivering such medication to the community should be explored.

Compliance of young children with ITN protection in rural Burkina Faso

BACKGROUND

Insecticide-treated bed nets (ITNs) are known to be highly effective in reducing malaria morbidity and mortality. The effectiveness of ITNs is largely influenced by behavioural factors and not much is known regarding such factors under programme conditions.

METHODS

This descriptive study was nested into a large ITN effectiveness study in rural Burkina Faso. During two cross-sectional surveys in the dry and rainy season of 2003, random samples of young children from nine representative villages (n = 180 per survey) were investigated for compliance with ITN protection and related behaviour. Data were collected through direct observations and through interviews with mothers.

RESULTS

ITNs were perceived as very important for protection against mosquitoes and malaria particularly during the rainy season, but there were problems with their use during the dry season. Young children usually slept with their mother under the ITN and self-reported compliance was 66% and 98% during dry and rainy season, respectively (confirmed by direct observation in 34% and 79%, respectively). Important reasons for low compliance during the dry season were high temperatures inside houses and problems related to changing sleeping places during the night.

CONCLUSION

Under programme conditions, compliance with ITN protection in young children is sufficient during the rainy season, but is rather low during the hot and dry season. Greater emphasis needs to be placed on information/education efforts to make people aware of the fact that the risk of contracting malaria may persist throughout the year.

Rolling out insecticide treated nets in Eritrea: examining the determinants of possession and use in malarious zones during the rainy season

OBJECTIVE

This paper describes determinants of insecticide treated net (ITN) ownership and use in malarious areas of Eritrea. With ITN distribution and re-treatment now free for all living in these areas, we examine barriers (other than cost) to access and use of ITNs. We explore the differences between use of an ITN as a proportion of all households in the survey (the roll back malaria indicator), and use of an ITN as a proportion of those households who already own an ITN.

METHODS

A modified two-stage cluster design was used to collect data from a sample of households (n = 2341) in the three most malarious administrative zobas (zones or provinces). Logistic regression was used to analyse the data.

RESULTS

Our findings suggest environmental heterogeneity among zobas (including program effects specific to each zoba), perception of risk, and proximity to a clinic are important predictors of ITN possession and use. Among households with at least one ITN, 17.0% reported that children under five were not under an ITN the night before the survey, while half of all such households did not have all occupants using them the night before the survey. The number of ITNs, as well as zoba, was also significant determinants of use in these households with at least one ITN.

CONCLUSION

Current efforts to disseminate ITNs to vulnerable populations in Eritrea are working, as suggested by high ITN ownership and net-to-person ratios inside households. However, the gap between ITN ownership and use, given ownership, is large, and may represent lost opportunities to prevent infection. Closing this gap requires concerted efforts to change behaviour to ensure that all household members use ITNs as consistently and correctly as possible during and following the rains.

Role of traditional healers in the management of severe malaria among children below five years of age: the case of Kilosa and Handeni Districts, Tanzania

BACKGROUND

The current malaria control strategy of WHO centres on early diagnosis and prompt treatment using effective drugs. Children with severe malaria are often brought late to health facilities and traditional health practitioners are said to be the main cause of treatment delay. In the context of the Rectal Artesunate Project in Tanzania, the role of traditional healers in the management of severe malaria in children was studied.

METHODOLOGY

A community cross-sectional study was conducted in Kilosa and Handeni Districts, involving four villages selected on the basis of existing statistics on the number of traditional health practitioners involved in the management of severe malaria. A total of 41 traditional health practitioners were selected using the snowballing technique, whereby in-depth interviews were used to collect information. Eight Focus Group Discussions (FGDs) involving traditional health practitioners, caregivers and community leaders were carried out in each district.

RESULTS

Home management of fever involving sponging or washing with warm water at the household level, was widely practiced by caregivers. One important finding was that traditional health practitioners and mothers were not linking the local illness termed degedege, a prominent feature in severe malaria, to biomedically-defined malaria. The majority of mothers (75%) considered degedege to be caused by evil spirits. The healing process was therefore organized in stages and failure to abide to the procedure could lead to relapse of degedege, which was believed to be caused by evil spirits. Treatment seeking was, therefore, a complex process and mothers would consult traditional health practitioners and modern health care providers, back and forth. Referrals to health facilities increased during the Rectal Artesunate Project, whereby project staff facilitated the process after traditional medical care with the provision of suppositories. This finding is challenging the common view that traditional healers are an important factor of delay for malaria treatment, they actually play a pivotal role by giving "bio-medically accepted first aid" which leads to reduction in body temperature hence increasing chances of survival for the child. Increasing the collaboration between traditional healers and modern health care providers was shown to improve the management of severe malaria in the studied areas.

INTERPRETATION AND CONCLUSION

Traditional health care is not necessarily a significant impediment or a delaying factor in the treatment of severe malaria. There is a need to foster training on the management of severe cases, periodically involving both traditional health practitioners and health workers to identify modalities of better collaboration.

Household decision-making process and childhood cerebral malaria in The Gambia

Mortality from childhood cerebral malaria remains unacceptably high in endemic regions. This survey was conducted between June and December 2001 among 69 primary caregivers of children admitted for cerebral malaria in Bansang Hospital, Central River Division (CRD), The Gambia to describe decision-making process at the family level that could have impact on malaria mortality. Thirty two percent of children presented in coma after 24 h of onset of illness. The eldest person in the compound or the father was responsible for taking decision on when hospital treatment was necessary in 85% of the cases. Mothers who were the primary caregivers made such decisions only in 7% of the cases. Cultural norms in a community are important factors affecting preferences at the household level and could influence important medical decisions. This survey suggests that patriarchs and/or fathers are important target groups for health education and project implementation programs.

Malaria prevention in The Gambia: patterns of expenditure and determinants of demand at the household level

OBJECTIVE

To provide a better understanding of (1) the amounts households in The Gambia spend on a wide variety of malaria prevention measures, (2) how expenditure fluctuates throughout the year and (3) the main determinants of expenditure.

METHODS

A random sample of 1700 households from the Farafenni region were interviewed about their expenditure on malaria prevention over the past 2 weeks. Interviews were staggered over 12 months. Expenditure was measured for bed nets, treating and repairing bed nets, aerosols, coils, indoor spraying, smoke and other prevention strategies such as drinking herbs and cleaning the outside environment. Results Expenditure on bed nets, including treatment and repair, constituted only 10% of total expenditure on malaria prevention. Every fortnight, households spent an average of 8.40 Dalasis (D) on coils, 4.20 D on indoor sprays, 3.09 D on smoke and 3.06 D on aerosols, together making up 81% of total fortnightly expenditure. Of the 442 households that did not own a bed net, 68% said it was because they could not afford one. Every 2 months, the same households spent an average of US 5 dollars, the equivalent to the cost of an insecticide treated bed net, on other forms of prevention. Total expenditure was 42% higher during the wet season than for the rest of the year. For every month of the year, coils were the dominant form of prevention expenditure. Wealth, age, occupation of household head, location of residence and month of the year were significant determinants of prevention expenditure.

CONCLUSIONS

Households in The Gambia spend considerable amounts on a range of malaria prevention products and activities throughout the year. Bed nets represent a relatively small proportion of this expenditure even though they are perceived to be the most efficient and effective method of malaria control. A more concerted effort is needed to develop appropriate targeting strategies to encourage bed net use especially for children <5 years of age. Equal emphasis should be given to addressing barriers to purchasing nets such as their relative high upfront cost.

Culturally compelling strategies for behaviour change: a social ecology model and case study in malaria prevention

Behaviour change is notoriously difficult to initiate and sustain, and the reasons why efforts to promote healthy behaviours fail are coming under increasing scrutiny. To be successful, health interventions should build on existing practices, skills and priorities, recognise the constraints on human behaviour, and either feature community mobilisation or target those most receptive to change. Furthermore, interventions should strive to be culturally compelling, not merely culturally appropriate: they must engage local communities and nestle within social and ecological landscapes. In this paper, we propose a social ecology perspective to make explicit the links between intention to change, actual behaviour change, and subsequent health impact, as relating to both theory-based models and practical strategies for triggering behaviour change. A social ecology model focuses attention on the contexts of behaviour when designing, implementing or critically evaluating interventions. As a case study, we reflect on a community-directed intervention in rural Gambia designed to reduce malaria by promoting a relatively simple and low-cost behaviour: repairing holes in mosquito bednets. In phase 1, contextual information on bednet usage, transactions and repairs (the 'social lives' of nets) was documented. In phase 2 (intervention), songs were composed and posters displayed by community members to encourage repairs, creating a sense of ownership and a compelling medium for the transmission of health messages. In phase 3 (evaluation), qualitative and quantitative data showed that household responses were particularly rapid and extensive, with significant increase in bednet repairs (p<0.001), despite considerable constraints on human agency. We highlight a promising approach-using songs-as a vehicle for change, and present a framework to embed the design, implementation and critical evaluation of interventions within the larger context-or social ecology-of behaviour practices that are the bedrock of health interventions.

Preventing malaria in pregnancy: a study of perceptions and policy implications in Mukono district, Uganda

Although the efficacy of insecticide-treated nets (ITNs) in malaria prevention is well documented, the low coverage of ITNs in malaria endemic countries necessitates investigation on factors that limit access to this intervention. An exploratory study was conducted in Mukono district, Uganda, to assess perceptions and use of ITNs. Results show that malaria is perceived as a serious illness among pregnant women and children, and there is high awareness on the benefits of ITNs. However, ITNs are used by few people, mainly because of their high cost and the perception that the chemicals used to treat them have dangerous effects on pregnancy and the foetus. Other factors that influence the use of ITNs include low utilization of antenatal care, husband's lack of interest in malaria prevention and the perception that adolescent girls and primigravidae are at a low risk of getting malaria. The policy implications of these findings include demystifying the negative perceptions on the chemicals used to treat nets and subsidizing the cost of ITNs in order to increase access to them. These findings provide important lessons for malaria control programmes that aim at increasing access to ITNs by pregnant women in developing countries.

Malaria: knowledge and behaviour in an endemic rural area of Turkey

This cross-sectional study was conducted to determine the knowledge and behaviour of people in the Sanliurfa province of Turkey regarding the prevention of malaria. A modified 30-cluster sampling method based on the traditional Expanded Programme for Immunization coverage surveys was employed to select a representative sample from 210 households. A questionnaire that focused on sociodemographic characteristics, knowledge and behaviour of malaria prevention, treatment-seeking behaviour and the use of antimalarials was applied. Eighty-nine percent of respondents knew at least one of the classical symptoms of malaria, and fever and chills were the most commonly reported symptoms (78.6%). Of the people interviewed, 33% believed that malaria can be acquired from dirty water, by changing place of residence, by working in cotton or tomato fields, or from malaria patients' belongings. None of the respondents knew how mosquitoes acquire the parasite. Twenty-five percent of respondents believed that elimination of breeding sites was one way to prevent malaria, and 8% identified the use of bednets. Fifty-five percent of respondents reported protective behaviours that are not directly associated with malaria transmission. Almost 47% of respondents reported that they completed their antimalarials, and only 21% of respondents indicated that they would seek treatment for febrile disease from physicians or a malaria unit. Understanding community perceptions of aetiology, symptom identification and treatment of malaria is an important step towards disease control.

Home treatment of 'malaria' in children in rural Gambia is uncommon

Home treatment with antimalarials is a common practice in many countries, and may save lives by ensuring that more malaria cases receive prompt treatment. Through retrospective surveys we found that home treatment of young children with antimalarials was uncommon in rural Gambia. Few families kept medicines in the home in case of illness, 28% kept paracetamol and only 8% kept chloroquine. Less than 10% of cases of childhood 'malaria' had been treated with chloroquine at home, and 69% of those giving home medication did not know the correct dosage for a child. The most common course of treatment was the use of paracetamol and/or tepid sponging to reduce fever, before the child was taken to a government health facility. Treating a child with antimalarials at home was more costly than other forms of treatment. The low cost associated with the use of health services for children and the limited availability of antimalarials outside major towns contribute to the high use of government health services. This shows that that home treatment cannot be assumed to be the predominant mode of malaria treatment throughout Africa, and highlights the need for country-specific policies based on accurate local knowledge of treatment practices in both rural and urban areas.

Local understanding, perceptions and reported practices of mothers/guardians and health workers on childhood malaria in a Tanzanian district--implications for malaria control

Knowledge on local understanding, perceptions and practices of care providers regarding management of childhood malaria are needed for better malaria control in urban, peri-urban and rural communities. Mothers of under five children attending five purposively selected public health facilities in the Kibaha district, Tanzania, were invited to participate in 10 focus group discussions (FGDs). The health workers of these facilities were included in six other FGDs to elicit their professional views. Analysis was done using interpretative and qualitative approaches. Both health workers and all mothers were clear about the signs and symptoms of homa ya malaria, a description consistent with the biomedical definition of mild malaria. Although most of the mothers related this to mosquito bites, some did not. Mothers also described a severe childhood illness called degedege, consistent with convulsions. Most of the mothers failed to associate this condition with malaria, believing it is caused by evil spirits. Urinating on or fuming the child suffering from degedege with elephant dung were perceived to be effective remedies while injections were considered fatal for such condition. Traditional healers were seen as the primary source of treatment outside homes for this condition and grandmothers and mother in-laws are the key decision makers in the management. Our findings revealed major gaps in managing severe malaria in the study communities. Interventions addressing these gaps and targeting mothers/guardians, mother in-laws, grandmothers and traditional healers are needed.

Changes in house design reduce exposure to malaria mosquitoes

House design may affect an individual's exposure to malaria parasites, and hence to disease. We conducted a randomized-controlled study using experimental huts in rural Gambia, to determine whether installing a ceiling or closing the eaves could protect people from malaria mosquitoes. Five treatments were tested against a control hut: plywood ceiling; synthetic-netting ceiling; insecticide-treated synthetic-netting ceiling (deltamethrin 12.5 mg/m2); plastic insect-screen ceiling; or the eaves closed with mud. The acceptability of such interventions was investigated by discussions with local communities. House entry by Anopheles gambiae, the principal African malaria vector, was reduced by the presence of a ceiling: plywood (59% reduction), synthetic-netting (79%), insecticide-treated synthetic-netting (78%), plastic insect-screen (80%, P < 0.001 in all cases) and closed eaves (37%, ns). Similar reductions were also seen with Mansonia spp., vectors of lymphatic filariasis and numerous arboviruses. Netting and insect-screen ceilings probably work as decoy traps attracting mosquitoes into the roof space, but not the room. Ceilings are likely to be well accepted and may be of greatest benefit in areas of low to moderate transmission and when used in combination with other malaria control strategies.

Medical syncretism with reference to malaria in a Tanzanian community

What happens when new health information is introduced into a community? We have explored this question in a semi-rural community of Southeastern Tanzania whose population has been in contact with biomedicine for many decades. With the example of malaria, we illustrate how biomedical knowledge transmitted in health messages coexists, interacts and merges with local pre-existing ideas and logics. The results are syncretic models, which may deviate considerably from what health promoters intended to transmit. Some of those may have implications for treatment of malaria, which may include delay in seeking treatment and non-compliance with therapy. Analysing this medical syncretism clearly demonstrates that even if comprehension of health messages is accurate, the way in which people interpret these messages may not be. Disentangling syncretic processes permits us to understand the dynamics of how information is processed by the recipients, and provides orientations for health promoters for adapting messages to the local context.

Community factors associated with malaria prevention by mosquito nets: an exploratory study in rural Burkina Faso

Malaria-related knowledge, attitudes and practices (KAP) were examined in a rural and partly urban multiethnic population of Kossi province in north-western Burkina Faso prior to the establishment of a local insecticide-treated bednet (ITN) programme. Various individual and group interviews were conducted, and a structured questionnaire was administered to a random sample of 210 heads of households in selected villages and the provincial capital of Nouna. Soumaya, the local illness concept closest to the biomedical term malaria, covers a broad range of recognized signs and symptoms. Aetiologically, soumaya is associated with mosquito bites but also with a number of other perceived causes. The disease entity is perceived as a major burden to the community and is usually treated by both traditional and western methods. Malaria preventive practices are restricted to limited chloroquine prophylaxis in pregnant women. Protective measures against mosquitoes are, however, widespread through the use of mosquito nets, mosquito coils, insecticide sprays and traditional repellents. Mosquito nets are mainly used during the rainy season and most of the existing nets are used by adults, particularly heads of households. Mosquito nets treated with insecticide (ITN) are known to the population through various information channels. People are willing to treat existing nets and to buy ITNs, but only if such services would be offered at reduced prices and in closer proximity to the households. These findings have practical implications for the design of ITN programmes in rural areas of sub-Saharan Africa (SSA).

Do untreated bednets protect against malaria?

Bednets are thought to offer little, if any, protection against malaria, unless treated with insecticide. There is also concern that the use of untreated nets will cause people sleeping without nets to receive more mosquito bites, and thus increase the malaria risk for other community members. Regular retreatment of nets is therefore viewed as critical for malaria control. However, despite good uptake of nets, many control programmes in Africa have reported low re-treatment rates. We investigated whether untreated bednets had any protective benefit (in October and November 1996) in The Gambia where nets, although widely used, are mostly untreated. Cross-sectional prevalence surveys were carried out in 48 villages and the risk of malaria parasitaemia was compared in young children sleeping with or without nets. Use of an untreated bednet in good condition was associated with a significantly lower prevalence of Plasmodium falciparum infection (51% protection [95% CI 34-64%], P < 0.001). This finding was only partly explained by differences in wealth between households, and children in the poorest households benefited most from sleeping under an untreated net (62% protection [14-83%], P = 0.018). There was no evidence that mosquitoes were diverted to feed on children sleeping without nets. These findings suggest that an untreated net, provided it is in relatively good condition, can protect against malaria. Control programmes should target the poorest households as they may have the most to gain from using nets.

Introducing insecticide-treated nets in the Kilombero Valley, Tanzania: the relevance of local knowledge and practice for an information, education and communication (IEC) campaign

Since 1997 the WHO has been recommending an integrative strategy to combat malaria including new medicines, vaccines, improvements of health care systems and insecticide-treated nets (ITNs). After successful controlled trials with ITNs in the past decade, large-scale interventions and research now focus on operational issues of distribution and financing. In developing a social marketing approach in the Kilombero Valley in south-east Tanzania in 1996, a combination of qualitative and quantitative methods was employed to investigate local knowledge and practice relating to malaria. The findings show that the biomedical concept of malaria overlaps with several local illness concepts, one of which is called malaria and refers to mild malaria. Most respondents linked malaria to mosquitoes (76%) and already used mosquito nets (52%). But local understandings of severe malaria differed from the biomedical concept and were not linked to mosquitoes or malaria. A social marketing strategy to promote ITNs was developed on the basis of these findings, which reinforced public health messages and linked them with nets and insecticide. Although we did not directly evaluate the impact of promotional activities, the sharp rise in ownership and use of ITNs by the population (from 10 to > 50%) suggests that they contributed significantly to the success of the programme. Local knowledge and practice is highly relevant for social marketing strategies of ITNs.

Impact of irrigation on malaria in Africa: paddies paradox

The high population growth rate of the African continent has led to an increased demand for food and is in danger of outstripping agricultural production. In order to meet this need, many governments have sought ways of improving food production by initiating large-scale irrigation projects, involving reclamation of arid and semi-arid areas for the cultivation of crops. Although crop irrigation promises one solution to alleviating hunger and encourages economic growth, irrigation has often been blamed for aggravating disease in local communities. Malaria is one of the major tropical diseases associated with irrigation schemes, and changes in the transmission pattern of this disease following irrigation development have been a perennial subject of debate. It has often been assumed that high numbers of malaria vector Anopheles mosquitoes (Diptera: Culicidae) resulting from irrigation schemes lead inevitably to increased malaria in local communities. However, recent studies in Africa have revealed a more complex picture. Increased numbers of vectors following irrigation can lead to increased malaria in areas of unstable transmission, where people have little or no immunity to malaria parasites, such as the African highlands and desert fringes. But for most of sub-Saharan Africa, where malaria is stable, the introduction of crop irrigation has little impact on malaria transmission. Indeed, there is growing evidence that for many sites there is less malaria in irrigated communities than surrounding areas. The explanation for this finding is still unresolved but, in some cases at least, can be attributed to displacement of the most endophilic and anthropophilic malaria vector Anopheles funestus Giles by An. arabiensis Patton with lower vectorial capacity, as the latter thrives more than the former in ricefields. Similarly, among members of the An. gambiae complex, some cytotypes of An. gambiae sensu stricto are more vectorial than others. For example, the Mopti form has high vectorial capacity and breeds perennially in irrigated sites, whereas the savanna form is often sympatric but more seasonal. Also we suggest that many communities near irrigation schemes benefit from the greater wealth created by these schemes. Consequently irrigation communities often have greater use of bednets, better access to improved healthcare and receive fewer infective bites compared with those outside such development schemes. Thus, in most cases, irrigation schemes in Africa do not appear to increase malaria risk, except in areas of unstable transmission. However, developers should take the opportunity to improve health-care facilities for local communities when planning irrigation schemes wherever they occur.

Cultural identity and illness: Fulani views

Cultural identity--who the Fulani think they are--informs thinking on illnesses they suffer. Conversely, illness, so very prevalent in sub-Saharan Africa, provides Fulani with a constant reminder of their distinctive condition in Guinea. How they approach being ill also tells Fulani about themselves. The manner in which Fulani think they are sick expresses their sense of difference from other ethnic groups. Schemas of illness and of collective identity draw deeply from the same well and web of thoughts. Three different approaches of schema theory are used to trace what ties illness to identity. These are 1) the schema as prototype; 2) a connectionist approach associates schemas for illness with other cultural schemas; and 3) a hierarchy of schemas. The hierarchy includes master schemas for ethnic identity, schemas for illness generally and sub-schemas for separate ailments. Schemas orient and provide a framework for the practice of being Fulani--in the sense that Bourdieu would describe practice as the application of practical knowledge. Illnesses above the waist are said to be part of the Fulani condition of belonging in arid climates while they need suffer the humidity of Guinea. Illnesses below the waist are thought to arise when one does not act like a Fulani, especially in matters of food and sex. As individuals disclose or conceal illness, as they discuss illness and the problem of others they reflect standards of Fulani life--being strong of character not necessarily of body, being disciplined, rigorously Moslem, and leaders among lessors. To disregard standards or to suggest one does not care about such standards is shameful and places one out of phase with others and with cultural norms. But to be in step with others and with cultural norms is to have pride in the self and the foundations of Fulani life.

Malaria control in central Malaita, Solomon Islands. 1. The use of insecticide-impregnated bed nets

The present study investigated the use of insecticide-impregnated bed nets by communities in central Malaita, Solomon Islands. Qualitative and quantitative data were collected by: (1) questionnaire administration to 124 care-givers of children aged 0-10 years of age; (2) 20 focus group discussions; (3) two structured observations of bed net re-impregnation, and (4) interviews with key informants. Ninety-four percent of all care-givers had bed nets, but only 62% had sufficient bed nets for all household members. Fifty-two percent used bed nets throughout the year and 70% of care-givers reported that all their children slept under bed nets. Although coastal householders considered malaria and mosquitoes more of a problem than inland householders, overall bed net compliance did not differ. Factors affecting bed net ownership were cost and community expectation of free bed nets. Bed net use was affected by four factors: (1) seasonality (99% used bed nets during the rainy season, 52% used them all year); (2) mosquito nuisance (59% of respondents reported that protection against mosquitoes was the main reason for using a bed net); (3) weather (68% of care-givers would not use a bed net if the weather was hot), and (4) low density of mosquitoes (respondents who used bed nets as protection against mosquito nuisance were more likely not to use bed nets when mosquitoes were few than those who used bed nets for malaria protection (odds ratio (OR), 3.9; 95% confidence interval (CI), 1.4-12.0). Protection against malaria was the main reason children slept under bed nets. Children from households where bed nets were used for malaria protection were more likely to sleep under bed nets than children from households where nets were used as protection from mosquitoes only (OR, 2.7; 95% CI, 1.3-5.9). Other factors that affected children's bed net use were, age (users were significantly younger than non-users; chi(2)=7.9, degrees of freedom=1, P=0.005) and sufficiency of bed nets (OR, 2.0; 95% CI, 1. 3-7.0).

Determinants of the Permethrin Impregnated Bednets (PIB) in the Republic of Benin: the role of women in the acquisition and utilization of PIBs

An important aspect of malaria control strategies has been the use of prophylactic measures such as impregnated bednets; however, adoption of this strategy has been slow and uneven. This study considers the factors determining Permethrin Impregnated Bednets (PIB) use in the context of a PIB promotion project in a rural area of Benin undertaken between 1992 and 1995. Quantitative data, on socio-demographic characteristics, malaria knowledge, attitudes, and practices, were gathered from 191 households of PIB users and non-users for comparative purposes using a questionnaire format. Qualitative data were collected from 23 focus group discussion sessions and 16 semi structured interviews. Women's income, men's educational level, and women's participation in communal organizations were the principal variables distinguishing user households from non-user households. Recourse to non-western medicine and, in particular, to medicinal teas which are considered preventive or curative correlates negatively with PIB use. The qualitative data shows that informants consider exposure to the sun, especially while engaged in agriculture work, a principal cause of malaria, and that PIB adoption is not considered justified in a context where there is a quasi chronic shortage of financial resources and where confidence in the efficacy of non-western medicine prevails. Because they have primary responsibility for the health of their families and are more aware of children's vulnerability to malaria, women are more inclined than men to want to buy PIBs. However, because the household head, who is most often male, sets family consumption priorities using family income, women often have to resort to using their own income, which is often considerably lower than that of men, to buy PIBs. Support for community initiatives which are directed to women's work, linked with intensive effort to sensitize men to the mechanisms of malaria transmission and the principal groups at risk, is seen as a means to increase PIB acquisition and use.

Knowledge, beliefs and practices relevant for malaria control in an endemic urban area of the Colombian Pacific

Research projects for malaria control must involve communities to elicit strategies to be successful and programs to be sustainable. Therefore, knowledge, beliefs and practices of the population concerned must be taken into account in the design of interventions against malaria transmission. We conducted a KAP study in Buenaventura, a port on the Pacific Coast of Colombia where transmission was on the increase at the beginning of this decade. The purpose of the study was to help in the design and implementation of a primary health care approach for malaria control. Both qualitative and quantitative research methods were used. The focus group technique was applied in five urban and peri-urban communities and a cross sectional survey was conducted on a random sample of 1380 subjects with a structured interview on knowledge, practices and also on demographic and epidemiological aspects. The information obtained by the two methods was comparable on knowledge of symptoms, causes and ways of malaria transmission, and prevention practices like the use of bednets or provision of health services. We discuss the relevance of obtaining this information and analyze the elements that must be taken into account for communities to become more involved in malaria control strategies.