Social and cultural aspects of 'malaria' and its control in central Côte d'Ivoire

Perceptions and behaviors of healthcare providers towards rehabilitation support to children with severe malaria-related disability in Ethiopia: A qualitative descriptive study using the Theoretical Domains Framework

INTRODUCTION

Severe malaria often results in childhood disability. The prevalence of disability related to severe malaria is significant and is estimated to affect up to 53% of severe malaria survivors. In contrast, information is sparse about how healthcare providers in Africa think about or provide rehabilitation support in acute and post-acute phases respectively. Understanding the perceptions and behaviors of healthcare providers treating malaria could help inform malaria-related disability research, policy, and practice, aimed at the providers themselves. This study explored the perceptions and behaviors of healthcare providers towards rehabilitation for children with severe malaria-related disability. The Theoretical Domains Framework was used to describe the findings relative to wider literature on health provider behavior change.

METHODS

A qualitative descriptive approach was used to interview thirteen healthcare providers recruited purposively based on their clinical professions, roles, and settings. Data were analyzed using directed content analysis. We decided on the most prominent theoretical domains considering the frequency of specific perceptions and behaviors across the participants, the frequency of perceptions and behaviors in each domain, and evidence of strong perceptions and behaviors.

RESULTS

Nine out of fourteen theoretical domains were identified. These domains were: Beliefs about consequences, environmental context and resources, goals, knowledge, skills, optimism, reinforcement, social influences, and social or professional role and identity. Healthcare providers' beliefs about their roles in screening for disability or referring to rehabilitation were less positive.

CONCLUSIONS

The findings of this study suggest the need for interventions to support healthcare providers in acute phases (prevention and control of severe malaria) and post-acute phases (disability screening, referral, and rehabilitation care). Recommended interventions should focus on developing clinical guidelines, training clinicians, addressing institutional factors, and modifying external social influences such as socio-cultural factors.

Factors influencing fever care-seeking for children under five years of age in The Gambia: a secondary analysis of 2019-20 DHS data

BACKGROUND

Malaria contributes to excess child mortality in The Gambia. Children under five are at risk of severe malaria and death if not treated promptly and appropriately. It is crucial that a child with fever receive appropriate care from a trained provider. The aim was to identify influences on child fever care-seeking in The Gambia to inform malaria control strategies.

METHODS

This cross-sectional analysis of The Gambia 2019-20 Demographic and Health Survey used logistic regression analysis to identify associations between source of care for a child with fever (public or private healthcare provider, other, or no treatment) and mother, child, and household characteristics.

RESULTS

Only 52.0% of mothers sought care from a trained healthcare provider for a child with fever-45.1% from a public facility and 7.0% from the private sector. 35.2% of mothers did not seek treatment. Mothers in urban households were 2.67 times as likely (aOR, 95% CI 1.504-4.736) as mothers in rural households to seek care from an informal source (e.g., pharmacy) versus not seeking treatment, and 0.29 times as likely (aOR, 95% CI 0.165-0.515) as mothers in rural households to seek care from a public provider versus informal source. Mothers in wealthier households were 2.30 times as likely (aOR, 95% CI 1.274-4.164) as mothers in poorer households to seek care from an informal source versus no treatment and half as likely as mothers in poorer households to seek care from a public provider versus informal source (aOR 0.53, 95% CI 0.291-0.959).

CONCLUSIONS

Maintaining The Gambia's malaria control achievements will require the active engagement and oversight of private pharmacies along with continued integrated community case management to reach mothers who do not seek care for a child with fever, and remove challenges to seeking appropriate care from trained providers. Whether influenced by convenience, costs, perceived urgency, or other factors, given the likelihood of urban mothers and mothers in wealthier households to seek care from private pharmacies, it will be necessary to incorporate private pharmacies into malaria control strategies while building public sector capacity and workforce, and initiating more effective attitude and behavioural change among mothers and households.

Community and health worker perspectives on malaria in Meghalaya, India: covering the last mile of elimination by 2030

BACKGROUND

Malaria remains a public health problem in regions of Northeastern India because of favourable bio-geographic transmission conditions, poor access to routine healthcare, and inadequate infrastructure for public health and disease prevention. This study was undertaken to better understand community members' and health workers' perceptions of malaria, as well as their knowledge, attitudes, and prevention practices related to the disease in Meghalaya state.

METHODS

The study included participants from three malaria endemic districts: West Khasi Hills, West Jaiñtia Hills, and South Garo Hills from 2019 to 2021. A total of 82 focus group discussions (FGD) involving 694 community members and 63 in-depth interviews (IDI) with health personnel and traditional healers residing within the three districts were conducted. A thematic content analysis approach was employed, using NVivo12 software for data management.

RESULTS

Most participants reported a perceived reduction in malaria during recent years, attributing this to changes in attitudes and behaviours in health seeking, and to more effective government interventions. Local availability of testing and treatment, and an improved, more responsive health system contributed to changing attitudes. Long-lasting insecticidal nets (LLINs) were largely preferred over indoor residual spraying (IRS), as LLINs were perceived to be effective and more durable. Community members also reported using personal protective measures such as applying repellents, burning neem tree leaves, straw/egg trays, wearing long sleeve clothes, and applying ointments or oils to protect themselves from mosquito bites. While most participants acknowledged the role of mosquitoes in malaria transmission, other conditions that are not mosquito-borne were also attributed to mosquitoes by some participants. The communities surveyed have largely shifted from seeking treatment for malaria from traditional healers to using public facilities, although some participants reported switching between the two or using both simultaneously. Improved understanding of cerebral malaria, which some participants previously attributed to mental illness due to 'bad spirits', is an example of how cultural and ritualistic practices have changed.

CONCLUSION

The findings reveal diverse perceptions among community members regarding malaria, its prevention, practices to prevent mosquito-transmitted diseases, and their opinions about the healthcare system. A key finding was the shift in malaria treatment-seeking preferences of community members from traditional healers to the public sector. This shift highlights the changing dynamics and increasing acceptance of modern healthcare practices for malaria treatment and prevention within tribal and/or indigenous communities. By recognizing these evolving attitudes, policymakers and healthcare providers can better tailor their interventions and communication strategies to more effectively address ongoing needs and concerns as India faces the 'last mile' in malaria elimination.

Knowledge, perceptions, and practices around zoonotic diseases among actors in the livestock trade in the Lake Victoria crescent ecosystem in East Africa

Background

Zoonotic diseases such as anthrax, rabies, brucellosis, and Rift Valley fever pose a direct threat to health and undercut livelihoods in the communities in which they occur. A combination of anthropogenic and animal activities like migration and interaction with wildlife and their respective parasites and vectors drives the emergence and re-emergence of zoonotic diseases. Consequently, One Health interdisciplinary approaches that incorporate social scientists can provide key insights into complex local perceptions. The approach calls for collaboration between the human and animal health sectors, including the sharing of disease surveillance data necessary to alleviate disease impacts. Livestock traders interact closely with livestock, which puts them at elevated risk of infection and creates conditions by which they may spread zoonotic disease. It is thus essential to examine practices among actors involved in the livestock trade to understand the most appropriate ways to mitigate these risks.

Methods

A qualitative study was conducted among the actors in the livestock trade in Busia County on their knowledge and perceptions of zoonotic diseases and practices that may contribute to the spread, control, and prevention of zoonotic disease transmission. A thematic analysis framework was used to categorize and synthesize data from in-depth interviews (IDIs), key informant interviews (KIIs), and structured observations.

Results

Whereas participants could list livestock diseases, they could not identify which ones were zoonoses, demonstrating insufficient knowledge of zoonosis. They identify sick animals by checking for dropped ears, excess mucus production, diarrhea, bloody urinal discharge, and general animal activity levels. To prevent the spread of these diseases, they wash their animals, isolate sick animals from the rest of the stock, and vaccinate their animals. They seek help from animal health professionals for sick animals as part of curative practices. This shows that they perceive the diseases as serious and that they need to be attended to by professionals. The results also show that they perceive animals from outside the region to be more vulnerable to diseases compared to those from within. The actors in the livestock trade engage in practices like skinning dead animals before burying them; to them, this is a normal practice. Some also consume dead carcasses. These increase the risk of zoonotic disease transmission.

Conclusion

The actors involved in the livestock trade are critical in the prevention and elimination of zoonotic diseases; hence, they need to be involved when developing intervention programs and policies for animal health extension services. Training them as a continuum of animal health workers blends lay and professional knowledge, which, alongside their intense contact with large numbers of animals, becomes a critical disease surveillance tool. Increasing awareness of zoonoses by using multi-disciplinary teams with social scientists is urgently needed so that practices like skinning dead animals before disposing of them and consumption of dead carcasses can be minimized.

Rice farmers' knowledge, attitudes and practices towards mosquitoes in irrigation schemes in Côte d'Ivoire: a qualitative study

BACKGROUND

Irrigated rice cultivation in sub-Saharan Africa not only brings more malaria vectors to nearby communities, but also greater malaria risk. To aid the implementation of mosquito control in rice-growing communities, it is necessary to understand how farmers understand, view and manage their responsibility in mosquito generation and whether they are interested in coordinating to minimize it.

METHODS

Qualitative methods (observation grids, semi-structured in-depth interviews and focus group discussions) were used to reveal the perceptions of mosquitoes and their control in two irrigated rice farming communities in central Côte d'Ivoire near the M'bé and Lokapli irrigation schemes.

RESULTS

All rice farmers viewed mosquitoes as severe nuisances, and most acknowledged that they caused djèkouadjo (malaria) and were less numerous during harmattan (dry season). Many study participants believed that mosquitoes originated from grasses and stagnant water around villages. Only those living closer in proximity (~ 1 km) to the paddies believed that mosquitoes came from the bas-fonds (irrigated lowlands). However, they did not associate mosquito production with rice cultivation. Some farmers believed that there were more mosquitoes in recent years than historically because of the dam construction, but remarked on the importance of the dam (and bas-fonds) for their livelihood. Many farmers were not convinced that mosquito control could occur at farm-level.

CONCLUSIONS

To enhance accountability amongst rice farmers, there is a need for greater awareness on the rice-mosquito link, and emphasis that the link does not imply a trade-off between food production and health. Training should not only be directed towards farming communities, but also agricultural and health extension workers. Future riceland mosquito control methods must focus on improving crop productivity and address collective action problems that may occur.

Community and health worker perspectives on malaria in Meghalaya, India: Covering the last mile of elimination by 2030

Background

Malaria remains a public health problem in regions of northeastern India due to favourable bio-geographic transmission conditions, poor access to routine healthcare, and inadequate public health and healthcare infrastructure. This study was undertaken to better understand community members' and health workers' perceptions of malaria, as well as their knowledge, attitudes, and prevention practices related to the disease in Meghalaya state.

Methods

The study included participants from three malaria endemic districts: West Khasi Hills, West Jaiñtia Hills, and South Garo Hills from 2019 to 2021. A total of 82 focus group discussions (FGD) with 694 community members and 63 in-depth interviews (IDI) with health personnel and traditional healers residing within the three districts were conducted. A thematic content analysis approach was employed, and NVivo12 software was utilized for data management.

Results

Most participants reported a perceived reduction in malaria during recent years and attributed this to changing attitudes and behaviours in health seeking behaviour and effective government interventions. Local availability of testing and treatment, and an improved, more responsive health system contributed to changing attitudes. Long-lasting insecticidal nets (LLINs) were largely preferred over indoor residual spraying (IRS), as LLINs were perceived to be effective and more durable. Community members also reported using personal protective measures such as applying repellents, burning straw/egg trays, wearing long sleeve clothes, and applying ointments or oils to protect themselves from mosquito bites. While most participants acknowledged the role of mosquitoes in malaria transmission, other conditions that are not mosquito-borne were also attributed to mosquitoes by some participants. The communities surveyed have largely shifted from seeking traditional healers to using public facilities, although some participants reported switching between the two or using both simultaneously. Using the example of improved understanding of cerebral malaria which was previously attributed to mental illness due to 'bad spirits', participants explained how cultural and ritualistic practices had changed.

Conclusions

Our findings reveal diverse perceptions among community members regarding malaria, its prevention, practices to prevent mosquito-transmitted diseases, and their opinions about the health system. A key finding was the shift in malaria treatment seeking preferences of community members from traditional healers to the public sector. This shift highlights the changing dynamics and increasing acceptance of modern healthcare practices for malaria treatment and prevention within tribal and/or indigenous communities. By recognizing these evolving attitudes, policymakers and healthcare providers can better tailor their interventions and communication strategies to more effectively address ongoing needs and concerns as India faces the 'last mile' in malaria elimination.

Knowledge, attitudes and practices regarding malaria prevention and control in communities in the Eastern Region, Ghana, 2020

BACKGROUND

In sub-Saharan Africa countries including Ghana, the malaria burden remains unacceptably high and still a serious health challenge. Evaluating a community's level of knowledge, attitude, and practice (KAP) regarding malaria is essential to enabling appropriate preventive and control measures. This study aimed to evaluate knowledge of malaria, attitudes toward the disease, and adoption of control and prevention practices in some communities across the Eastern Region of Ghana.

METHODS

A cross‑sectional based study was carried out in 13 communities across 8 districts from January -June, 2020. Complete data on socio-demographic characteristics and KAP were obtained from 316 randomly selected household respondents by a structured pre-tested questionnaire. Associations between KAP scores and socio-demographic profiles were tested by Chi-square and binary logistic regression. Data analysis was done with SPSS version 26.0.

RESULTS

Most respondents (85.4%) had good knowledge score about malaria. Preferred choice of treatment seeking place (50.6%) was the health center/clinic. All respondents indicated they would seek treatment within 24 hours. Mosquito coils were the preferred choice (58.9%) against mosquito bites. Majority of households (58.5%) had no bed nets and bed net usage was poor (10.1%). Nearly half of the respondents (49.4%) had a positive attitude toward malaria and 40.5% showed good practices. Chi-square analysis showed significant associations for gender and attitude scores (p = 0.033), and educational status and practice scores (p = 0.023). Binary logistic regression analysis showed that 51-60 year-olds were less likely to have good knowledge (OR = 0.20, p = 0.04) than 15-20 year-olds. Respondents with complete basic schooling were less likely to have good knowledge (OR = 0.33, p = 0.04) than those with no formal schooling. A positive attitude was less likely in men (OR = 0.61, p = 0.04). Good malaria prevention practice was lower (OR = 0.30, p = 0.01) in participants with incomplete basic school education compared to those with no formal schooling.

CONCLUSION

Overall scores for respondents' knowledge, though good, was not reflected in attitudes and levels of practice regarding malaria control and prevention. Behavioral change communication, preferably on radio, should be aimed at attitudes and practice toward the disease.

Education and Socio-economic status are key factors influencing use of insecticides and malaria knowledge in rural farmers in Southern Côte d'Ivoire

BACKGROUND

Insecticides play a key role in rural farming; however, their over- or misuse has been linked with a negative impact on malaria vector control policies. This study was conducted amongst agricultural communities in Southern Côte d'Ivoire to identify which insecticides are used by local farmers and how it relates to the perception of farmers on malaria. Understanding the use of insecticides may help in designing awareness programme on mosquito control and pesticides management.

METHODS

A questionnaire was administered to 1399 farming households across ten villages. Farmers were interviewed on their education, farming practices (e.g. crops cultivated, insecticides use), perception of malaria, and the different domestic strategies of mosquito control they use. Based on some pre-defined household assets, the socioeconomic status (SES) of each household was estimated. Statistical associations were calculated between different variables, showing significant risk factors.

RESULTS

The educational level of farmers was significantly associated with their SES (p < 0.0001). Most of the householders (88.82%) identified mosquitoes as the principal cause of malaria, with good knowledge of malaria resulting as positively related to high educational level (OR = 2.04; 95%CI: 1.35, 3.10). The use of indoor chemical compounds was strongly associated to the SES of the households, their education level, their use of ITNs and insecticide in agricultural (p < 0.0001). Indoor application of pyrethroid insecticides was found to be widespread among farmers as well as the use of such insecticide for crops protection.

CONCLUSION

Our study shows that the education level remains the key factor influencing the use of insecticides by farmers and their awareness of malaria control. We suggest that better communication tailored to education level and including SES, controlled availability and access to chemical products, should be considered when designing campaigns on use of pesticides and vector borne disease control for local communities.

The control of malaria vectors in rice fields: a systematic review and meta-analysis

The relatively stable aquatic conditions of irrigated lowland and rainfed rice, which is grown across 145 million hectares in more than 100 countries, are capable of generating large numbers of mosquito vectors of malaria, which causes more than 400,000 deaths per year worldwide. Many methods can control these vectors, but a systematic review has not previously been conducted. This study assesses whether larviciding, fish or intermittent irrigation can significantly reduce malaria vectors in rice fields whilst increasing rice yield. After a literature search for studies reporting the effect of larval control and rice cultivation practices on malaria vector densities in rice fields, 33 studies were eligible for meta-analysis. Larviciding was effective at reducing rice-field malaria vectors. Pooled analysis of five controlled time-series (CTS) studies with chemical insecticides showed an overall combined reduction of larval densities of 77% compared to no larviciding. Eight CTSs with biological larvicides showed a pooled reduction of 60% compared to no larviciding. Cultivating rice and fish together provided good control too: a pooled analysis of three CTSs showed an overall 82% reduction in anopheline larvae compared to no fish. Pooled analysis of four studies suggested that intermittent irrigation (using various timings and frequencies of drainage) is effective at reducing the abundance of late-stage anopheline larvae (pooled reduction = - 35%), but not overall immature abundance, compared to continuous flooding. We conclude that many interventions such as larvicides, fish and intermittent irrigation can provide riceland malaria vector control, but the critical obstacle to wider use is farmer acceptability. Future research should be led by the agricultural sector, with inputs from entomologists, to investigate malaria control co-benefits within high-yielding rice cultivation practices.

A Systematic Review of Tropical Disease Prevalence among Migrants

BACKGROUND: Few studies have assessed the burden of tropical diseases among migrants into non-endemic countries. AIM: This study aimed to systematically review the existing data of the prevalence of tropical diseases globally, including neglected tropical diseases globally. MATERIALS AND METHODS: The authors conducted a systematic review reporting prevalence (including seroprevalence) of tropical diseases following the PRISMA guidelines and based on the database from PUBMED, WoS, and PROQUEST. All the identified records were screened according to the inclusion and exclusion criteria. The selected articles’ quality was appraised using the mixed methods appraisal tool to ensure its quality. RESULTS: Overall, 19 studies conducted in 13 countries published between the year 2017–2020 were included in the study. Based on the thematic analysis, two themes (type of organism) and 11 sub-themes (disease) were used. The prevalence of tropical diseases among migrants ranged from 0.2 to 31% for malaria; 3–20% for Chagas Disease; 3.2–3.5% for Giardiasis; 31.7–57.4% for Toxoplasmosis; 0.1–51%, for Schistosomiasis; 0.1–15.8%, for Strongyloidiasis; 0.3–3.8% for Trichuriasis; 0.2–0.9% for Ascariasis; 6.4–9.7% for Toxocariasis; 0.3% for Loiasis; and 0.5% for Filariasis. All migrants warrant thorough screening and testing, based on the country of origin of their last visit. Routine screening and follow-up may reduce the re-emergence of tropical disease in non-endemic countries. CONCLUSION: Multiple approaches in managing social and health issues among migrants are vital to secure healthy labor forces for the country’s economy and development. Public health sectors should implement strategic promotive, preventive, and curative programs targeted to this group.

Mazingira and the malady of malaria: Perceptions of malaria as an environmental disease in contemporary Zanzibar

This paper addresses how contemporary Zanzibaris perceive the relationship between the mazingira (roughly translated as "environment") and the malady of malaria. More broadly, this article presents data exploring Zanzibari conceptions of the mazingira, the relationship between the mazingira and malaria, and who Zanzibaris believe are responsible for acting on, or for, the mazingira in regards to malaria. We use the biomedical disease malaria-and the local syncretic understanding of it, which we recognize by referring to it as the "malady of malaria"-as a lens to investigate Zanzibari conceptions of the mazingira. We highlight the need to integrate local forms of knowledge, which we refer to as vernacular knowledge. 50 interviews show that Zanzibaris believe the mazingira can be modified in positive ways to cleaner, safer spaces that will also reduce malaria levels. People expressed widespread agreement that there is a clear relationship between the mazingira and the malady of malaria, though they differed in what exactly the relationship was.

Quantifying the effect of human population mobility on malaria risk in the Peruvian Amazon

The impact of human population movement (HPM) on the epidemiology of vector-borne diseases, such as malaria, has been described. However, there are limited data on the use of new technologies for the study of HPM in endemic areas with difficult access such as the Amazon. In this study conducted in rural Peruvian Amazon, we used self-reported travel surveys and GPS trackers coupled with a Bayesian spatial model to quantify the role of HPM on malaria risk. By using a densely sampled population cohort, this study highlighted the elevated malaria transmission in a riverine community of the Peruvian Amazon. We also found that the high connectivity between Amazon communities for reasons such as work, trading or family plausibly sustains such transmission levels. Finally, by using multiple human mobility metrics including GPS trackers, and adapted causal inference methods we identified for the first time the effect of human mobility patterns on malaria risk in rural Peruvian Amazon. This study provides evidence of the causal effect of HPM on malaria that may help to adapt current malaria control programmes in the Amazon.

Knowledge and practices surrounding malaria and LLIN use among Arab, Dazagada and Fulani pastoral nomads in Chad

Background

Chadian pastoral nomads are highly exposed to malaria due to their lifestyle and their mobility between various endemic areas. To inform strategies to reduce nomads’ risk of malaria and associated morbidity and mortality, it is important to understand the factors associated to their knowledge of malaria transmission and prevention practices.

Methods

A cross–sectional study among Arab, Dazagada and Fulani pastoral nomadic groups was conducted in February and October 2021. A validated structured electronic questionnaire was administered to assess knowledge of malaria. Attitudes and malaria prevention practices were assessed on the basis of perception of the causes of malaria and the use of a long-lasting insecticide-treated net (LLIN) the day before the survey. Data were analyzed using Chi—square tests and multivariate logistic regression with covariates adjustment.

Results

A total of 278 nomads aged 20 to 65 years were included in the study. Overall, 90.7% of participants surveyed had a good knowledge of malaria. Fulani respondents were more likely to have a good knowledge of malaria than Arab respondents (Adjusted Odd ratio (AOR): 5.00, 95% CI: 1.04–24.03) and households possessing a LLIN were more likely to have a good knowledge of malaria (AOR: 9.66, 95% CI: 1.24–75.36). Most nomad households surveyed reported sleeping under a mosquito net the night before the survey (87.1%) while 98.9% owned a LLIN. Daza respondents (AOR: 0.23, 95% CI: 0.09–0.56) were less likely to use LLINs than Arab respondents. The middle (AOR: 2.78, 95% CI: 1.17–6.62) and wealthier households (AOR: 6.68, 95% CI: 3.19–14.01) were more likely to use LLINs. Knowledge of malaria was associated with the use of LLIN (AOR: 12.77, 95% CI: 1.58–102.99).

Conclusion

There remains a need to improve nomads’ understanding of Plasmodium falciparum-carrying mosquitoes as the vector for malaria transmission and the quality of information provided. Knowledge of malaria and its prevention strategies in nomadic setting lead to the use of LLINs. Further reductions in malaria morbidity can be achieved by improving nomads’ access to LLINs. This study can inform on the design policies to improve nomadic communities’ knowledge of malaria prevention and promoting LLIN use as requested by the national policy against malaria.

Rural-Urban Differentials in Access to Behaviour Change Communication and Use of Long-Lasting Insecticide-Treated Nets and Artemisinin-Based Combination Therapy in Southeast Nigeria

BACKGROUND

As Malaria continues to take a heavy toll on the life and economy of Nigerians, The National Malaria Elimination Programme uses behaviour change communication (BCC) to promote the use of Long-Lasting Insecticide-treated Nets (LLIN) and Artemisinin-based Combination Therapy (ACT) to combat malaria. This study examined the impact of BCC on the use of LLIN and ACT in Southeast Nigeria.

METHODS

A structured questionnaire was used to gather data from 480 respondents in urban and rural communities across five states. Analysis of data was done using percentages, chi-square and logistic regression.

RESULTS

Findings showed weak effect of BCC on LLIN and ACT use despite achieving high (93.75%) exposure. Only 45.1% and 45.7% of the respondents used LLIN and ACT respectively. Urban residents were found to sleep under LLINs and use ACTs more than rural dwellers. Regression results showed that newspapers (OR=1.341) and the Internet (OR=3.216) increased the odds of LLIN use in the rural areas and magazines (OR=1.837) in the urban areas. Television (OR=2.375; P=0.002) and the Internet (OR=6.063; P=0.001) increased the odds of ACT use in the urban areas. Education was found to be a positive predictor of LLIN use in the rural (OR=4.645; P=0.011) and urban areas (OR=6.102) as well as ACT use in the rural (OR=7.268; p=0.002) and urban areas (0R=6.145; P=0.009).

CONCLUSION

Access to behaviour change communication though very high has not achieved the desired behaviour change. The National Malaria Elimination Programme should produce appropriate messages to address barriers to LLIN and ACT use.

Assessing community knowledge, attitude and practices to strengthen communication strategy for Malaria Elimination Demonstration Project in Mandla

BACKGROUND

Changes in social, belief, and behavioural practices are essential for the success of any public health delivery programme. In the planning stages of the Malaria Elimination Demonstration Project (MEDP), priority was given to communication with a goal to develop capacity of health workers and to improve the knowledge, attitude and practices (KAP) of the people of Mandla. This paper describes the level of community knowledge on malaria, including its prevention, diagnosis, treatment-seeking behaviour, and the level of satisfaction with the services provided by the project.

METHODS

A cross sectional survey was undertaken in 1233 villages of Mandla to study the KAP and self-assessed improvement in knowledge and satisfaction level of the community. The goal of the study was to understand whether there is need for strengthening communication strategy of MEDP for better impact. The survey was conducted amongst the head/eligible members of the 733 households located in the nine blocks of the district using clustered random sampling.

RESULTS

Though four-fifths of the respondents were able to correlate the transmission of malaria with mosquitoes, misconceptions existed among them. The types of malaria were not known to everyone. Only 39% were aware of the Indoor Residual Spray (IRS) and 41% understood the value of Long-Lasting Insecticidal Nets (LLIN). Around 71% of subjects surveyed were aware of the proper diagnostic tests for malaria. A total of 87% of the respondents knew about the MEDP staff working in their respective villages.

CONCLUSION

The study reported gaps in knowledge on malaria at community level. The self-assessment of the community revealed that the communication strategy established by MEDP in Mandla district has been useful to them as they are becoming better informed about the prevention and treatment aspects of disease. The lessons learned as revealed in the KAP survey will improve malaria elimination outcomes in a timely manner.

Use of Insecticides in Agriculture and the Prevention of Vector-Borne Diseases: Population Knowledge, Attitudes, Practices and Beliefs in Elibou, South Côte d'Ivoire

People’s knowledge, attitudes, practices and beliefs (KAPB) pertaining to malaria are generally well described. However, little is known about population knowledge and awareness of insecticide resistance in malaria vectors. The aim of this study was to investigate KAPB related to insecticide resistance in malaria vectors due to the use of insecticides in agriculture and the prevention against mosquitoes. In mid-2017, we carried out a cross-sectional survey in Elibou, South Côte d’Ivoire, employing a mixed methods approach. Quantitative data were obtained with a questionnaire addressed to household heads. Interviews were conducted with key opinion leaders, including village chiefs, traditional healers, heads of health centres and pesticide sellers. Focus group discussions were conducted with youth and elders. A total of 203 individuals participated in the questionnaire survey (132 males, 65%). We found that people had good knowledge about malaria and mosquitoes transmitting the disease, while they felt that preventing measures were ineffective. Pesticides were intensively used by farmers, mainly during the rainy season. Among the pesticides used, insecticides and herbicides were most commonly used. While there was poor knowledge about resistance, the interviewees stated that insecticides were not killing the mosquitoes anymore. The main reason given was that insecticides were diluted by the manufacturers as a marketing strategy to sell larger quantities. More than a third of the farmers used agricultural pesticides for domestic purposes to kill weeds or mosquitoes. We observed a misuse of pesticides among farmers, explained by the lack of specific training. In the community, long-lasting insecticidal nets were the most common preventive measure against malaria, followed by mosquito coils and insecticide sprays. The interviewees felt that the most effective way of dealing with insecticide resistance was to combine at least two preventive measures. In conclusion, population attitudes and practices related to insecticides used in agriculture and the prevention against mosquitoes could lead to resistance in malaria vectors, while people’s knowledge about insecticide resistance was limited. There is a need to raise awareness in communities about the presence of resistance in malaria vectors and to involve them in resistance management.

A Transdisciplinary Approach to Managing Emerging and Resurging Mosquito-Borne Diseases in the Western Pacific Region

Mosquitoes transmit a number of harmful diseases that have an impact on local communities and visitors, and many pose a threat to neighboring countries. As federal monitoring budgets shrink across the world, the increasing importance of citizen scientists in monitoring and identifying invasive species, as well as acting to prevent these diseases, are discussed. Examples of past mosquito management programs are provided, and future directions are discussed with an emphasis on the Western Pacific Region.

Multi-dimensional knowledge of malaria among Nigerian caregivers: implications for insecticide-treated net use by children

Background

Poor malaria knowledge can negatively impact malaria control programmes. This study evaluates knowledge distribution in the domains of causation, transmission, vulnerability, symptoms, and treatment of malaria. It assesses the association between a caregiver’s knowledge about malaria and ownership and use of insecticide-treated nets (ITNs) by children.

Methods

Some 1939 caregivers of young children were recruited through a school-based survey in two Nigerian states. A 20-item, multi-dimensional survey instrument was developed and used to rank each caregiver’s knowledge in five dimensions (cause, transmission, vulnerability, symptoms, treatment of malaria). Scores for each domain were used to create an aggregate knowledge score for each caregiver. The outcome measures were ITN ownership, and ITN use the night and week before the study. Regression models were used to evaluate the relationship between caregiver’s knowledge (individual domains and aggregate score) and ownership and use of ITN after controlling for likely confounders.

Results

The main predictor of ITN use was ITN ownership (r = 0.653; p < 0.001); however, ownership only explains 43 % of variance in net use. Total knowledge index for the study population was significantly associated with both ITN ownership (r = 0.122; p = 0.001) and use (r = 0.095; p = 0.014). The spectrum of caregiver’s knowledge of malaria and its causes captured in the various domains was, however, found to be poor. Fifty percent of the respondents knew that malaria is transmitted by female mosquitoes and 65 % still believe that too much exposure to the sun is a risk factor for malaria. Knowledge of populations most vulnerable to malaria (83 %) and knowledge of malaria transmission (32 %) were the domains with the highest and lowest average correct answers.

Conclusions

There is a need to improve ITN coverage in Nigeria as ITN ownership was associated with ITN use. Additionally, treating knowledge as a multi-dimensional phenomenon revealed that a lot of misperceptions about malaria still exist. Distribution of ITNs through the public/private sector may need to be augmented with tailored behavioural change communication to dispel myths and improve the multi-dimensional knowledge of malaria in the local population.

"Tazomoka Is Not a Problem". Local Perspectives on Malaria, Fever Case Management and Bed Net Use in Madagascar

Background

Although its incidence has been decreasing during the last decade, malaria is still a major public health issue in Madagascar. The use of Long Lasting Insecticidal Nets (LLIN) remains a key malaria control intervention strategy in Madagascar, however, it encounters some obstacles. The present study aimed to explore the local terminology related to malaria, information channels about malaria, attitude towards bed nets, and health care seeking practices in case of fever. This article presents novel qualitative findings about malaria. Until now, no such data has been published for Madagascar.

Methods

A comparative qualitative study was carried out at four sites in Madagascar, each differing by malaria epidemiology and socio-cultural background of the populations. Seventy-one semi-structured interviews were conducted with biomedical and traditional caregivers, and members of the local population. In addition, observations of the living conditions and the uses of bed net were conducted.

Results

Due to the differences between local and biomedical perspectives on malaria, official messages did not have the expected impact on population in terms of prevention and care seeking behaviors. Rather, most information retained about malaria was spread through informal information circulation channels. Most interviewees perceived malaria as a disease that is simple to treat. Tazomoka (“mosquito fever”), the Malagasy biomedical word for malaria, was not used by populations. Tazo (“fever”) and tazomahery (“strong fever”) were the terms more commonly used by members of the local population to refer to malaria related symptoms. According to local perceptions in all areas, tazo and tazomahery were not caused by mosquitos. Each of these symptoms required specific health recourse. The usual fever management strategies consisted of self-medication or recourse to traditional and biomedical caregivers. Usage of bed nets was intermittent and was not directly linked to protection against malaria in the eyes of most Malagasy people.

Conclusions

This article highlights the conflicting understanding of malaria between local perceptions and the biomedical establishment in Madagascar. Local perceptions of malaria present a holistic vision of the disease that includes various social and cultural dimensions, rather than reflecting one universal understanding, as in the biomedical image. The consideration of this “holistic vision” and other socio-cultural aspects surrounding the understanding of malaria is essential in implementing successful control intervention strategies.

Disparities of Plasmodium falciparum infection, malaria-related morbidity and access to malaria prevention and treatment among school-aged children: a national cross-sectional survey in Côte d'Ivoire

BACKGROUND

There is limited knowledge on the malaria burden of school-aged children in Côte d'Ivoire. The aim of this study was to assess Plasmodium falciparum infection, malaria-related morbidity, use of preventive measures and treatment against malaria, and physical access to health structures among school-aged children across Côte d'Ivoire.

METHODS

A national, cross-sectional study was designed, consisting of clinical and parasitological examinations and interviews with schoolchildren. More than 5,000 children from 93 schools in Côte d'Ivoire were interviewed to determine household socioeconomic status, self-reported morbidity and means of malaria prevention and treatment. Finger-prick blood samples were collected and Plasmodium infection and parasitaemia determined using Giemsa-stained blood films and a rapid diagnostic test (RDT). Haemoglobin levels and body temperature were measured. Children were classified into wealth quintiles using household assets and principal components analysis (PCA). The concentration index was employed to determine significant trends of health variables according to wealth quintiles. Logistic and binomial negative regression analyses were done to investigate for associations between P. falciparum prevalence and parasitaemia and any health-related variable.

RESULTS

The prevalence of P. falciparum was 73.9% according to combined microscopy and RDT results with a geometric mean of parasitaemia among infected children of 499 parasites/μl of blood. Infection with P. falciparum was significantly associated with sex, socioeconomic status and study setting, while parasitaemia was associated with age. The rate of bed net use was low compared to the rate of bed net ownership. Preventive measures (bed net ownership, insecticide spray and the reported use of malaria treatment) were more frequently mentioned by children from wealthier households who were at lower risk of P. falciparum infection. Self-reported morbidity (headache) and clinical morbidity (anaemia) were more often reported by children from less wealthy households.

CONCLUSION

Seven out of ten school-aged children in Côte d'Ivoire are infected with P. falciparum and malaria-related morbidity is considerable. Furthermore, this study points out that bed net usage is quite low and there are important inequalities in preventive measures and treatment. These results can guide equity-oriented malaria control strategies in Côte d'Ivoire.

Micro-encapsulated pirimiphos-methyl shows high insecticidal efficacy and long residual activity against pyrethroid-resistant malaria vectors in central Côte d'Ivoire

Background

The wide-scale implementation of insecticide-treated nets and indoor residual spraying (IRS) has contributed to a considerable decrease of malaria morbidity and mortality in sub-Saharan Africa over the last decade. Due to increasing resistance in Anopheles gambiae sensu lato mosquitoes to dichlorodiphenyl trichloroethane (DDT) and pyrethroids, alternative insecticide formulations for IRS with long-lasting residual activity are required to sustain the gains obtained in most malaria-endemic countries.

Methods

Three experimental capsule suspension (CS) formulations of the organophosphate pirimiphos-methyl were evaluated together with Actellic 50 EC, an emulsifiable concentrate (EC) of pirimiphos-methyl, and the pyrethroid ICON 10 CS, a lambda-cyhalothrin CS formulation, in an experimental hut trial. The formulations were tested on two types of surfaces: mud and cement. The study with a 12-month follow-up was carried out in Bouaké, central Côte d’Ivoire, where An. gambiae mosquitoes show high levels of resistance against pyrethroids, DDT and carbamates. Residual activity was also tested in cone bioassays with the susceptible An. gambiae KISUMU strain.

Results

One of the CS formulations of pirimiphos-methyl, CS BM, outperformed all other formulations tested. On cement surfaces, the odds ratios of overall insecticidal effect on An. gambiae s.l. of pirimiphos-methyl CS BM compared to Actellic 50 EC were 1.4 (95% confidence interval (CI): 1.2–1.7) for the first three months, 5.6 (95% CI: 4.4–7.2) for the second three months, and 3.6 (95% CI: 3.0–4.4) for the last six months of follow-up. On mud surfaces, the respective odds ratios were 2.5 (95% CI: 1.9–3.3), 3.5 (95% CI: 2.7–4.5), and 1.7 (95% CI: 1.4–2.2). On cement, the residual activity of pirimiphos-methyl CS BM measured using cone tests was similar to that of lambda-cyhalothrin and for both treatments, mortality of susceptible Kisumu laboratory strain was not significantly below the World Health Organization pre-set threshold of 80% for 30 weeks after spraying. Residual activity was shorter on mud surfaces, mortality falling below 80% on both pirimiphos-methyl CS BM and lambda-cyhalothrin treated surfaces at 25 weeks post-treatment.

Conclusion

CS formulations of pirimiphos-methyl are promising alternatives for IRS, as they demonstrate prolonged insecticidal effect and residual activity against malaria mosquitoes.

Electronic supplementary material

The online version of this article (doi:10.1186/1475-2875-13-332) contains supplementary material, which is available to authorized users.

Lay perceptions of malaria and therapeutic itinerary of resettled pregnant women in South Sudan

BACKGROUND

Approximately 95% of South Sudan is malaria-endemic and transmission is high throughout the year. Annually, 2.3 million people are at risk of malarial infection, but children under 5 years, pregnant women and their unborn children are particularly at high risk. Appropriate policies for malarial prevention and control require a better understanding of the populations' malarial perceptions and treatment itinerary.

METHODS

A qualitative study was carried out to explore malarial lay perceptions and therapeutic itinerary among 30 resettled pregnant women in Unity State, South Sudan.

RESULTS

The study showed that the therapeutic itinerary was prompted by fever and composed of five steps that were simultaneously or successively explored. The household and community constitute the first-line treatment options for fever. Interviewees relied on homemade remedies and concoctions, traditional healers' cures, magician's rituals and private formal and informal medicine vendors at the local market before seeking malarial diagnosis and treatment at the health centre.

CONCLUSIONS

Improving capacities for proper identification and management of malarial fever at household and community level is a priority for reducing the delay in seeking timely and proper treatment. The formal health system may, in time, aspire to address the economic and cultural barriers within the system that contribute to delaying effective treatment-seeking.

Plasmodium falciparum infection and clinical indicators in relation to net coverage in central Côte d'Ivoire

BACKGROUND

Sleeping under a net, particularly a long-lasting insecticidal net (LLIN), is associated with reduced malaria morbidity and mortality, but requires high coverage and adherence. In this study, parasitologically confirmed Plasmodium falciparum infection and a clinical indicator (i.e. fever) were measured among children in three villages of central Côte d'Ivoire (Bozi, N'Dakonankro and Yoho) and associations with net coverage explored. In Bozi and Yoho, LLINs were provided by the national malaria control programme, prior to the study and an additional catch-up coverage was carried out in Bozi. In N'Dakonankro, no net intervention was conducted.

METHODS

Three cross-sectional surveys were carried out; two in the dry season (February 2010 and November 2011) and one in the rainy season (May 2012). Among 897 children aged <15 years, P. falciparum infection was determined by microscopy and a rapid diagnostic test (RDT). Fever was defined as an axillary temperature ≥37.5°C. A questionnaire was administered to obtain demographic data and net usage.

RESULTS

The proportion of children infected with P. falciparum according to microscopy in the third survey was 74%, 81% and 82% in Yoho, N'Dakonankro and Bozi, respectively. Meanwhile, 46% of the children in N'Dakonankro, 44% in Bozi and 33% in Yoho slept under a net. The risk of P. falciparum infection did not differ between net-sleepers and non-net-sleepers. Fewer children had parasitaemia ≥1,000 parasites/μl of blood in Bozi in the third compared to the first survey. Fever was poorly correlated with P. falciparum infection. The risk of P. falciparum infection did not depend on the village of residence, presence of fever or sleeping under LLIN the night before the survey. Conversely, it was higher in the rainy season and among older children.

CONCLUSIONS

In an area where P. falciparum is highly prevalent, the use of nets was associated with significantly lower levels of parasitaemia. The apparent lack of effect on P. falciparum infection and fever might be explained by the relatively low net coverage in Bozi and Yoho and the relatively short period (<2 years) during which the impact of nets was measured.

A review of malaria transmission dynamics in forest ecosystems

Malaria continues to be a major health problem in more than 100 endemic countries located primarily in tropical and sub-tropical regions around the world. Malaria transmission is a dynamic process and involves many interlinked factors, from uncontrollable natural environmental conditions to man-made disturbances to nature. Almost half of the population at risk of malaria lives in forest areas. Forests are hot beds of malaria transmission as they provide conditions such as vegetation cover, temperature, rainfall and humidity conditions that are conducive to distribution and survival of malaria vectors. Forests often lack infrastructure and harbor tribes with distinct genetic traits, socio-cultural beliefs and practices that greatly influence malaria transmission dynamics. Here we summarize the various topographical, entomological, parasitological, human ecological and socio-economic factors, which are crucial and shape malaria transmission in forested areas. An in-depth understanding and synthesis of the intricate relationship of these parameters in achieving better malaria control in various types of forest ecosystems is emphasized.

Transmission of malaria in relation to distribution and coverage of long-lasting insecticidal nets in central Côte d'Ivoire

Background

The use of long-lasting insecticidal nets (LLINs) is an effective malaria control strategy. However, there are challenges to achieve high coverage, such as distribution sustainability, and coverage keep-up. This study assessed the effect of LLINs coverage and contextual factors on entomological indicators of malaria in rural Côte d’Ivoire.

Methods

The study was carried out between July 2009 and May 2012 in three villages (Bozi, N’Dakonankro and Yoho) of central Côte d’Ivoire. In Bozi and Yoho, LLINs were distributed free of charge by the national malaria control programme in 2008. In Bozi, an additional distribution was carried out in May 2011. No specific interventions were done in N’Dakonankro. Entomological surveys were conducted in July 2009 and July 2010 (baseline), and in August and November 2011 and in February 2012. Frequency of circumsporozoite protein was determined using an enzyme-linked immunosorbent assay. Regression models were employed to assess the impact of LLINs and changing patterns of irrigated rice farming on entomological parameters, and to determine associations with LLINs coverage and other contextual factors.

Results

In Bozi, high proportion of LLIN usage was observed (95-100%). After six months, 95% of LLINs were washed at least once and 79% were washed up to three times within one year. Anopheles gambiae was the predominant malaria vector (66.6% of all mosquitoes caught). From 2009 to 2012, in N’Dakonankro, the mean annual entomological inoculation rate (EIR) increased significantly from 116.8 infectious bites/human/year (ib/h/y) to 408.8 ib/h/y, while in the intervention villages, the EIR decreased significantly from 514.6 ib/h/y to 62.0 ib/h/y (Bozi) and from 83.9 ib/h/y to 25.5 ib/h/y (Yoho). The risk of an infectious bite over the three-year period was significantly lower in the intervention villages compared to the control village (p <0.001).

Conclusion

High coverage and sensitization of households to use LLINs through regular visits (particularly in Bozi) and abandoning irrigated rice farming (in Yoho) resulted in highly significant reductions of EIR. The national malaria control programme should consider household sensitization and education campaigns and other contextual factors to maximize the benefit of LLINs.

[Community perceptions of malaria vaccines : qualitative research from the sanitary districts of Kaya and Hounde in Burkina Faso]

Au Burkina Faso, le paludisme est la principale cause de mortalité chez les enfants de moins de 5 ans. L’un des moyens les plus efficaces de prévention des maladies reste la vaccination. Aucun vaccin antipaludique n’existe actuellement, mais la recherche pour développer un vaccin progresse. Si les résultats des essais cliniques sont concluants d’ici 2014, l’Organisation Mondiale de la Santé (OMS) pourrait recommander l’utilisation d’un vaccin anti-paludique dès 2015. C’est dans le but de guider la décision d’introduire éventuellement un vaccin contre le paludisme que cette étude a été menée. Les objectifs étaient de comprendre les perceptions et les expériences des communautés au sujet du paludisme et des vaccins et d’explorer l’acceptabilité éventuelle d’un vaccin antipaludique par ces communautés. Cette étude qualitative s’appuie sur le cadre socioécologique de L. W. Green. Elle s’est déroulée dans les districts sanitaires de Kaya et Houndé, au Burkina Faso. Au total, 30 groupes de discussions dirigées et 29 entretiens individuels ont été réalisés. Tous les participants à l’étude ont reconnu que le paludisme représente la première cause de morbidité et de mortalité au sein de leur communauté. En général, les populations de Kaya et Houndé ont eu des expériences positives avec les programmes de vaccination existant. Les effets bénéfiques que pourrait avoir un futur vaccin sont les motifs d’acceptation. L’avis du chef de ménage, l’interaction entre les prestataires de soins et les usagers des services de santé, et les effets secondaires sont des obstacles potentiels. Les résultats de cette étude fournissent des informations aux décideurs pour l’élaboration d’une stratégie de communication à l’éventuelle introduction d’un vaccin contre le paludisme. Pour surmonter les obstacles à l’introduction d’un nouveau vaccin, une stratégie de communication efficace devra formuler des messages appropriés, et identifier des canaux d’information et les publics cibles en tenant compte du contexte local.

Comparison of cold water sponging and acetaminophen in control of Fever among children attending a tertiary hospital in South Nigeria

Background:

A wide range of childhood illnesses are accompanied by fever, leading to varied attempts at treatment by caregivers at home before coming to a hospital. Common modalities of treatment include use of antipyretics and physical methods such as cold water sponging, fanning and removal of clothing. These treatment modalities have been received with varied attitudes among physicians and the scientific community. This study was to assess the efficacy of both modalities in first-line management of fever in our area.

Objectives:

The main aim of the study is to compare the effectiveness of cold water sponging with that of oral paracetamol in the treatment of fever in children attending the University of Calabar Teaching Hospital, Calabar.

Subjects and Methods:

This is a randomized clinical trial. Eighty-eight children aged 12-120 months who presented to the Children Outpatient Clinic (CHOP) and the Children Emergency Room (CHER) of University of Calabar Teaching Hospital, Calabar, with acute febrile illness and axillary temperatures spanning ≥ 38.0-40.0°C. All children within the age limit whose caregivers gave consent were recruited into the study and were randomized to receive either cold water sponging or oral paracetamol. Axillary temperature, pulse rate, respiratory rate and assessment of discomforts (crying, shivering, goose pimples and convulsions) were recorded every 30 min for 2 h. The results were analyzed using the SPSS statistical software and have been presented in the tables.

Results:

Cold water sponging was very effective in temperature reduction within the first 30 min, with 29 (70.73%) having their temperature reduced to within normal limits. This declined to 12 (29.26%) at 60 min and 4 (10.53%) at 120 min, with the mean temperature differences from the baseline value following the same trends (1.63°C by 30 min, 0.91°C by 60 min and 0.39°C by 120 min). When compared with paracetamol, cold water sponging was more effective in temperature reduction within the first 30 min (P = 0.000), with the difference in effect at 60 min less significant between these two groups (P = 0.229). Paracetamol demonstrated a gradual and sustained reduction in temperature with the proportions of afebrile children in this group increasing from 7 (16.27%) at 30 min to 33 (78.57%) at 120 min. The mean temperature differences from the baseline value also showed the same trend. Children who received cold water sponging had more discomforts compared with those who received only oral paracetamol.

Conclusions:

It is concluded that cold water sponging, although producing rapid reduction in temperature compared with paracetamol, has effects that last only for a short time. Paracetamol on the other hand produces a gradual but sustained effect. The discomforts experienced should not be a limiting factor to the use of cold water sponging in reducing the body temperature of febrile children. Cold water sponging is safe and its use by mothers and primary caregivers should be encouraged while preparing to take the child to the nearest health facility for definitive treatment of the underlying cause of the fever.

Local concepts of anemia-related illnesses and public health implications in the Taabo health demographic surveillance system, Côte d'Ivoire

BACKGROUND

A 14-month prospective longitudinal study conducted in the Taabo health demographic surveillance system (HDSS), south-central Côte d'Ivoire, revealed high prevalence of anemia in different population groups in three types of settings (i.e., small town, village, and hamlet). Demographic parameters and several variables related to parasitic infections, micronutrient status, and inflammation were significantly associated with higher odds of anemia. However, cultural concepts and knowledge of various anemia-related illnesses and their relation with people's behaviors have not been investigated.

METHODS

Sixteen focus group discussions and six key informant interviews were performed with village authorities, health workers, and traditional healers. Questionnaires were administrated to 200 school-aged children and 115 young women. Of these individuals, 206 participated in the preceding longitudinal study, whereas the remaining 109 people were not exposed to prior research, but had similar age and sex profiles. Mean prominence of participants' responses was compared between groups of participants and across study settings.

RESULTS

Local concepts of anemia-related illnesses referred to its perceived causes based on two logical frameworks - biomedical and sociocultural - although a clear distinction was often blurred. We found few differences in knowledge, beliefs, and behaviors across study settings and between participants who were exposed to prior research and newly recruited ones. Malaria und nutritional issues as understood and managed by the population differed from definitions and recommendations provided by the health system. Malaria was not acknowledged as an exclusive mosquito-transmitted disease and participants referred to the quantity, rather than the quality, of food when talking about nutritional issues.

CONCLUSIONS

Local concepts and ideas about anemia have public health implications, inasmuch as they are related to people's attitudes, risk-related and help-seeking behaviors, which in turn might affect their health status. Local terminology and beliefs about anemia and malaria should be carefully considered when developing health intervention and education programs. The similarity in knowledge about anemia-related illnesses and associated behaviors, regardless of study setting and prior exposure to research, suggests that a uniform communication strategy may be used to develop education programs and awareness campaigns aimed at the prevention and control of anemia in south-central Côte d'Ivoire.

Community-directed educational intervention for malaria elimination in Bhutan: quasi-experimental study in malaria endemic areas of Sarpang district

Background

As per the World Malaria Report 2011, there was a 17% reduction in morbidity and 26% reduction in mortality in 2010, compared to 2000. In Bhutan, there were only 194 malaria cases in 2011 as compared to 5,935 cases in 2000. As the country moves towards an elimination phase, educating the community and empowering them on malaria prevention and control is imperative. Hence, this study was conducted to elucidate the effectiveness of the community-directed educational intervention on malaria prevention and control in malaria-endemic areas of Sarpang district, Bhutan.

Methods

This quasi-experimental study design was conducted using both qualitative and quantitative data collection methods. In-depth interviews and focus group discussions were carried out in addition to household survey using a structured questionnaire conducted before and after the intervention. Intervention was conducted using community action groups, who were provided with training and which then developed action plans for implementation of interventions within their communities.

Results

The study resulted in a significant improvement in knowledge and attitude in intervention as compared to control during the post-intervention survey (p < 0.001). The practice score was higher in the control group both during pre- and post-intervention, however, the mean ( ±sd) score of practice in intervention group increased from 6.84 ± 1.26 in pre-intervention to 8.35 ± 1.14 in post-intervention (p < 0.001), where as it decreased from 9.19 ± 1.78 to 9.10 ± 1.98 in the control group (p = 0. 68). When comparing pre- and post- in the intervention group, there was significant improvement during post-intervention in knowledge, attitude and practice (p < 0.001).

Conclusions

The findings from this study corroborate that community-directed interventions can be utilized as an effective means for improving knowledge, attitude and practice in the malaria-endemic areas of Bhutan. Further studies are needed to see the long-term effect and sustainability of such interventions.

Willingness to use a rapid diagnostic test for malaria in a rural area of central Côte d'Ivoire

Background

Malaria mortality is mainly a direct consequence of inadequate and/or delayed diagnosis and case management. Some important control interventions (e.g. long-lasting insecticidal nests) have contributed to reduce malaria morbidity and mortality in different parts of the world. Moreover, the development and effective use of rapid diagnostic tests (RDTs) hold promise to further enhance the control and elimination of malaria, particularly in areas where health services are deficient. The aim of this study was to determine knowledge, attitudes, practices and beliefs in relation to RDTs for malaria in rural Côte d’Ivoire.

Methods

One hundred individuals from Bozi and Yoho who sought care at the health centre in Bozi and were offered an RDT for malaria were interviewed in April 2010 using a pre-tested questionnaire on practice and perceptions in relation to RDTs for malaria. The relationships between acceptance of RDTs and factors related to opinions were identified, using generalized linear mixed models. Qualitative data from open-ended questions complemented the quantitative analysis.

Results

Only 34 out of 100 patients who were offered an RDT for malaria were willing to undergo the test. People who perceived blood as a sacred body fluid were less likely to comply with an RDT. The concurrent availability and use of RDTs for HIV and malaria was associated with an unwilling attitude towards RDTs for malaria (Fisher’s exact test, p <0.001). The initial willingness of patients to accept malaria testing with RDTs was significantly related to general fear and wanting to know malaria infection status. For further and regular use of RDTs, a strong relationship was observed between acceptance and the idea that an RDT is a pretext used by health worker to know HIV status (odds ratio (OR) = 16.61, 95% confidence interval (CI) = 1.03-268.5). Those thinking that blood samples were useful for medical diagnoses were 8.31-times (95% CI = 2.22-31.1) more likely to undergo an RDT compared to those rejecting blood sampling as a diagnostic strategy.

Conclusion

Socio-cultural factors might be barriers for accepting RDTs in general health services. There are social representations of malaria and HIV/AIDS, symbolic for blood or experiences in relation to blood taking and blood-related diseases in relation to the introduction and routine use of RDTs. Special attention should be given to these barriers as otherwise the promotion of RDTs for prompt and effective diagnosis and subsequent management of malaria is hampered.

Promoting community knowledge and action for malaria control in rural Cambodia: potential contributions of Village Malaria Workers

Background

Cambodia has been investing in Village Malaria Workers (VMWs) to improve malaria case management in rural areas. This study assessed the quality of the VMWs’ services compared to those by a government-run health center from the perspective of community members. We focused on VMWs’ contribution to promote their action to control malaria. A community-based cross-sectional study was conducted in Kampot province in 2009. Interviews were conducted at every accessible household in a village with VMWs (n = 153) and a village with a health center (n = 159), using interviewer administered questionnaire. Preference of the interview was given to female household head. Multiple regression analyses were run to compare knowledge about malaria, preventive measures taken, and time before first malaria treatment between the two villages.

Findings

The villagers perceived the VMWs’ services equally as good as those provided by the health center. After controlling for confounding factors, the following indicators did not show any statistical significance between two villages: community members’ knowledge about malaria transmission (AOR = 0.60, 95% CI = 0.30-1.22) and government-recommended antimalarial (AOR = 0.55, 95% CI = 0.25-1.23), preventive measures taken (Beta = −0.191, p = 0.315), and time before the first treatment (Beta = 0.053, p = 0.721). However, knowledge about malaria symptoms was significantly lower in the village with VMWs than the village with a health center (AOR = 0.40, 95% CI = 0.19-0.83).

Conclusions

VMWs played an equivalent role as the health center in promoting malaria knowledge, action, and effective case management. Although VMWs need to enhance community knowledge about malaria symptoms, the current government policy on VMWs is reasonable and should be expanded to other malaria endemic villages.

An alternative paradigm for the role of antimalarial plants in Africa

Most investigations into the antimalarial activity of African plants are centered on finding an indigenous equivalent to artemisinin, the compound from which current frontline antimalarial drugs are synthesized. As a consequence, the standard practice in ethnopharmacological research is to use in vitro assays to identify compounds that inhibit parasites at nanomolar concentrations. This approach fails to take into consideration the high probability of acquisition of resistance to parasiticidal compounds since parasite populations are placed under direct selection for genetic that confers a survival advantage. Bearing in mind Africa's long exposure to malaria and extensive ethnobotanical experimentation with both therapies and diet, it is more likely that compounds not readily overcome by Plasmodium parasites would have been retained in the pharmacopeia and cuisine. Such compounds are characterized by acting primarily on the host rather than directly targeting the parasite and thus cannot be adequately explored in vitro. If Africa's long history with malaria has in fact produced effective plant therapies, their scientific elucidation will require a major emphasis on in vivo investigation.

Intermittent preventive treatment of malaria in children: a qualitative study of community perceptions and recommendations in Burkina Faso and Mali

Background

Intermittent preventive treatment of malaria in children (IPTc) is a highly efficacious method of malaria control where malaria transmission is highly seasonal. However, no studies published to date have examined community perceptions of IPTc.

Methods

A qualitative study was undertaken in parallel with a double-blind, placebo-controlled, randomized trial of IPTc conducted in Mali and Burkina Faso in 2008–2009 to assess community perceptions of and recommendations for IPTc. Caregivers and community health workers (CHWs) were purposively sampled. Seventy-two in-depth individual interviews and 23 focus group discussions were conducted.

Findings

Widespread perceptions of health benefits for children led to enthusiasm for the trial and for IPTc specifically. Trust in and respect for those providing the tablets and a sense of obligation to the community to participate in sanctioned activities favoured initial adoption. IPTc fits in well with existing understandings of childhood illness. Participants did not express concerns about the specific drugs used for IPTc or about providing tablets to children without symptoms of malaria. There was no evidence that IPTc was perceived as a substitute for bed net usage, nor did it inhibit care seeking. Participants recommended that distribution be “closer to the population”, but expressed concern over caregivers' ability to administer tablets at home.

Conclusions

The trial context mediated perceptions of IPTc. Nonetheless, the results indicate that community perceptions of IPTc in the settings studied were largely favourable and that the delivery strategy rather than the tablets themselves presented the main areas of concern for caregivers and CHWs. The study identifies a number of key questions to consider in planning an IPTc distribution strategy. Single-dose formulations could increase the success of IPTc implementation, as could integration of IPTc within a package of activities, such as bed net distribution and free curative care, for which demand is already high.

Malaria knowledge and long-lasting insecticidal net use in rural communities of central Côte d'Ivoire

Background

To improve effectiveness of malaria control interventions, it is essential to deepen the knowledge of contextual factors that govern people's practice for preventive and curative measures. The aim of this study was to determine factors that influence the use of long-lasting insecticidal nets (LLINs) in three rural communities of Côte d'Ivoire, two of which benefited from recent interventions.

Methods

The study was carried out in 957 households in three villages (Bozi, N'Dakonankro and Yoho) located in central Côte d'Ivoire. Indicators of socioeconomic position (SEP), malaria knowledge and practice, placing special emphasis on LLINs, were investigated during a cross-sectional questionnaire survey. Principal component analysis was used to calculate the SEP of households by means of a list of household assets ownership. The concentration index was used to assess the direction of the association between SEP and a given variable. To compare groups or means, Fisher's exact test, χ² and Kruskal-Wallis test were used, as appropriate.

Results

Significant differences were found between SEP and reported malaria symptoms, such as fever or hot body, convulsion, anaemia and jaundice (yellow eyes). Individuals from the least poor group cited more often the use of bed nets and insecticide-treated nets (ITNs) compared to poorer groups. The mean number of individuals reporting the use of bed nets and LLINs was different between groups with different educational level. Moreover, the mean number of LLINs in a household was influenced by the presence of children below five years of age.

Conclusion

The study not only confirmed that education and SEP play important roles in the prevention and control of malaria and promotion of health in general, but pointed at the basic essential knowledge and the key behavioural elements that should guide education and learning processes among the poorer segments of the population. In turn, such knowledge may change behaviour and lead to an increased utilization of LLINs.

Community perceptions of malaria and vaccines in the South Coast and Busia regions of Kenya

BACKGROUND

Malaria is a leading cause of morbidity and mortality in children younger than 5 years in Kenya. Within the context of planning for a vaccine to be used alongside existing malaria control methods, this study explores sociocultural and health communications issues among individuals who are responsible for or influence decisions on childhood vaccination at the community level.

METHODS

This qualitative study was conducted in two malaria-endemic regions of Kenya--South Coast and Busia. Participant selection was purposive and criterion based. A total of 20 focus group discussions, 22 in-depth interviews, and 18 exit interviews were conducted.

RESULTS

Participants understand that malaria is a serious problem that no single tool can defeat. Communities would welcome a malaria vaccine, although they would have questions and concerns about the intervention. While support for local child immunization programs exists, limited understanding about vaccines and what they do is evident among younger and older people, particularly men. Even as health care providers are frustrated when parents do not have their children vaccinated, some parents have concerns about access to and the quality of vaccination services. Some women, including older mothers and those less economically privileged, see themselves as the focus of health workers' negative comments associated with either their parenting choices or their children's appearance. In general, parents and caregivers weigh several factors--such as personal opportunity costs, resource constraints, and perceived benefits--when deciding whether or not to have their children vaccinated, and the decision often is influenced by a network of people, including community leaders and health workers.

CONCLUSIONS

The study raises issues that should inform a communications strategy and guide policy decisions within Kenya on eventual malaria vaccine introduction. Unlike the current practice, where health education on child welfare and immunization focuses on women, the communications strategy should equally target men and women in ways that are appropriate for each gender. It should involve influential community members and provide needed information and reassurances about immunization. Efforts also should be made to address concerns about the quality of immunization services--including health workers' interpersonal communication skills.

Appropriating "malaria": local responses to malaria treatment and prevention in Abidjan, Cote d'Ivoire

A continuing dilemma for medical and public health professionals is the apparent lack of fit between global and local knowledge systems and technologies. This is illustrated in relationship to malaria, with implications in the management of the disease. Ethnographic research was conducted from 2003-2005 in urban Abidjan, Cote d'Ivoire, on community understandings of malaria and the relationship of this to its prevention and control. Malaria is referred to locally as palu, reflecting the incorporation of malaria into a local illness taxonomy. Although the labeling of malaria-related symptoms as palu has wide currency, preventive measures such as bed nets, as advocated by public health authorities, have not been accepted readily or evenly. Drawing on theoretical understandings of the introduction, transfer, and appropriation of concepts and material objects, we examine the processes of localization in relation to malaria in Abidjan, and in doing so, highlight the challenges for health professionals seeking to scale-up public health interventions.

Malaria risk behaviours, socio-cultural practices and rural livelihoods in southern Tanzania: implications for bednet usage

Most malaria risk reduction strategies are firmly embedded in biomedical practices and public health perspectives. National and international programmes to 'control' malaria are particularly characterised by the promotion of public health interventions which converge on the disease vector, the malaria mosquito, notably through the use of indoor household spraying with insecticides, and the deployment of insecticide-treated bednets (ITNs). With convincing evidence for the effectiveness of ITNs in reducing the incidence of malaria, control programmes have emphasised the notion of 'scaling-up' bednet coverage. Much previous research on people's 'compliance' with bednet programmes has tended to focus on the quantification of bednet usage and on deriving explanations for 'non-compliance' based on household or individual indicators such as wealth, age, gender or educational level, or on climatic factors such as season and temperature. However, malaria risk behaviours are also rooted in wider aspects of local livelihoods, and socio-cultural beliefs and practices which interplay with the use and, crucially, non-use, of bednets. This paper draws on empirical data derived from in-depth, one-to-one semi-structured interviews, focus groups and participatory methods (mapping and diagramming) with participants in two villages in rural Tanzania to explore the nature of these practices and vulnerabilities, and their potential impact on malaria exposure risk. Participants included farmers and pastoralists, both men and women, as well as village 'officials'. By eliciting local understandings of malaria-related behaviours we explore how malaria risks are played out in people's everyday lives, and the circumstances and decision-making which underpin non-usage of bednets. Our findings reveal the importance of shifting sleeping patterns in response to livelihood needs and socio-cultural practices and events. These arrangements militate against the consistent and sustained use of the bednet which are called for by public health policies. In particular we demonstrate the importance of the spatial and temporal dimensions of farming practices and the role of conflict over access to shared land; the impact of livelihood activities on malaria risks for school-aged children; risk behaviours during 'special' socio-cultural events such as funeral ceremonies; and routine, outdoor activities around dawn and dusk and the gendered nature of these practices.

The use of insecticide-treated nets for reducing malaria morbidity among children aged 6-59 months, in an area of high malaria transmission in central Côte d'Ivoire

BACKGROUND

Long-lasting insecticidal nets (LLINs) are an important tool for controlling malaria. Much attention has been devoted to determine both the effect of LLINs on the reduction of Plasmodium infection rate and on clinically-confirmed malaria cases in sub-Saharan Africa. We carried out an epidemiological study to investigate whether LLINs impact on Plasmodium prevalence rate and the proportion of clinically-confirmed malaria cases, in five villages in the district of Toumodi, central Côte d'Ivoire.

METHODS

From April 2007 to November 2008, a community-based malaria control programme was implemented in the study villages, which involved large-scale distribution of LLINs, and training and sensitization activities within the community. We determined the effect of this programme on Plasmodium prevalence rate, clinically-confirmed malaria cases and proportion of high parasitaemia rates in children aged 6-59 months through a series of cross-sectional surveys starting in April 2007 and repeated once every 6 months.

RESULTS

We observed a significant decrease in the mean P. falciparum prevalence rate from April 2007 to April 2008 (p = 0.029). An opposite trend was observed from November 2007 to November 2008 when P. falciparum prevalence rate increased significantly (p = 0.003). Highly significant decreases in the proportions of clinical malaria cases were observed between April 2007 and April 2008 (p < 0.001), and between November 2007 and November 2008 (p = 0.001).

CONCLUSIONS

Large-scale distribution of LLINs, accompanied by training and sensitization activities, significantly reduced Plasmodium prevalence rates among young children in the first year of the project, whereas overall clinical malaria rates dropped over the entire 18-month project period. A decrease in community motivation to sleep under bed nets, perhaps along with changing patterns of malaria transmission, might explain the observed increase in the Plasmodium prevalence rate between November 2007 and November 2008.

Effects of seasonality and irrigation on malaria transmission in two villages in Côte d'Ivoire

The seasonality of malaria transmission was investigated in two villages in central Côte d'Ivoire: one usually with irrigated rice farming (Zatta) and one without (Tiémélékro). Adult mosquitoes were collected, from February 2002 to August 2005, inside and outside sentinel houses. In Tiémélékro, the biting rate of Anopheles gambiae s.s. showed a significant difference between the dry and rainy season only in 2003 (P<0.001). The corresponding rates for An. funestus s.s. showed significant seasonal differences in both 2002 and 2003 (P<0.001 for each year). In Zatta in 2003-2004, when irrigated rice farming was interrupted, there was no significant difference between the An. gambiae s.s. biting rates recorded in the dry and rainy seasons. In both 2002 and 2005, however, when irrigated rice farming was practised, the An. gambiae s.s. biting rate recorded in Zatta during the rainy season was significantly higher than that seen in the dry season (P<0.001 for each year). With just one exception (in Tiémélékro in 2005, the prevalence of Plasmodium infection in the An. funestus was significantly higher in the rainy season than in the dry season), no significant seasonal differences were seen in the prevalences of Plasmodium infection among the An. gambiae or An. funestus. In conclusion, although malaria transmission is quite stable in central Côte d'Ivoire throughout the year, it can be distinctly modified by irrigated rice farming.

Knowledge, attitudes and practices about malaria among communities: comparing epidemic and non-epidemic prone communities of Muleba district, North-western Tanzania

BACKGROUND

Muleba district in North-western Tanzania has experienced malaria epidemics in recent years. Community knowledge, attitudes and practices are important in enhancing disease control interventions. This study investigated determinants of malaria epidemics in the study area in relation to household knowledge, attitudes and practice on malaria.

METHODS

A community based cross-sectional survey involving 504 study participants was conducted between April and June 2007 using a structured questionnaire focusing on knowledge, attitudes and practices of community members in epidemic and non-epidemic villages about malaria transmission, signs and symptoms, treatment, prevention and control. Multivariate logistic regression analysis was used to assess determinants of malaria epidemics.

RESULTS

A total of 504 respondents (males = 36.9%) were interviewed. Overall, 453 (90.1%) mentioned malaria as the most important disease in the area. Four hundred and sixty four respondents (92.1%) knew that malaria is transmitted through mosquito bite. A total of 436 (86.7%), 306 (60.8%) and 162 (32.1%) mentioned fever, vomiting and loss of appetite as major symptoms/signs of malaria, respectively. Of those interviewed 328 (65.1%) remembered the recent outbreak of 2006. Of the 504 respondents interviewed, 296 (58.7%) reported that their households owned at least one mosquito net. Three hundred and ninety seven respondents (78.8%) knew insecticides used to impregnate bed nets. About two thirds (63.3%) of the respondents had at least a household member who suffered from malaria during the recent epidemic. During the 2006 outbreak, 278 people (87.2%) sought treatment from health facilities while 27 (8.5%) obtained drugs from drug shops and 10 (3.1%) used local herbs. Logistic regression analysis showed that household location and level of knowledge of cause of malaria were significant predictors of a household being affected by epidemic.

CONCLUSIONS

Residents of Muleba district have high level of knowledge on malaria. However, this knowledge has not been fully translated into appropriate use of available malaria interventions. Our findings suggest that household location, ineffective usage of insecticide treated nets and knowledge gaps on malaria transmission, signs and symptoms, prevention and control predisposed communities in the district to malaria epidemics. It is important that health education packages are developed to address the identified knowledge gaps.

Barriers to the effective treatment and prevention of malaria in Africa: A systematic review of qualitative studies

BACKGROUND

In Africa, an estimated 300-500 million cases of malaria occur each year resulting in approximately 1 million deaths. More than 90% of these are in children under 5 years of age. To identify commonly held beliefs about malaria that might present barriers to its successful treatment and prevention, we conducted a systematic review of qualitative studies examining beliefs and practices concerning malaria in sub-Saharan African countries.

METHODS

We searched Medline and Scopus (1966-2009) and identified 39 studies that employed qualitative methods (focus groups and interviews) to examine the knowledge, attitudes, and practices of people living in African countries where malaria is endemic. Data were extracted relating to study characteristics, and themes pertaining to barriers to malaria treatment and prevention.

RESULTS

The majority of studies were conducted in rural areas, and focused mostly or entirely on children. Major barriers to prevention reported included a lack of understanding of the cause and transmission of malaria (29/39), the belief that malaria cannot be prevented (7/39), and the use of ineffective prevention measures (12/39). Thirty-seven of 39 articles identified barriers to malaria treatment, including concerns about the safety and efficacy of conventional medicines (15/39), logistical obstacles, and reliance on traditional remedies. Specific barriers to the treatment of childhood malaria identified included the belief that a child with convulsions could die if given an injection or taken to hospital (10/39).

CONCLUSION

These findings suggest that large-scale malaria prevention and treatment programs must account for the social and cultural contexts in which they are deployed. Further quantitative research should be undertaken to more precisely measure the impact of the themes uncovered by this exploratory analysis.

Effect of agricultural activities on prevalence rates, and clinical and presumptive malaria episodes in central Côte d'Ivoire

Agricultural activities, among other factors, can influence the transmission of malaria. In two villages of central Côte d'Ivoire (Tiémélékro and Zatta) with distinctively different agro-ecological characteristics, we assessed Plasmodium prevalence rates, fever and clinically confirmed malaria episodes among children aged 15 years and below by means of repeated cross-sectional surveys. Additionally, presumptive malaria cases were monitored in dispensaries for a 4-year period. In Tiémélékro, we observed a decrease in malaria prevalence rates from 2002 to 2005, which might be partially explained by changes in agricultural activities from subsistence farming to cash crop production. In Zatta, where an irrigated rice perimeter is located in close proximity to human habitations, malaria prevalence rates in 2003 were significantly lower than in 2002 and 2005, which coincided with the interruption of irrigated rice farming in 2003/2004. Although malaria transmission differed by an order of magnitude in the two villages in 2003, there was no statistically significant difference between the proportions of severe malaria episodes (i.e. axillary temperature>37.5 degrees C plus parasitaemia>5000 parasites/microl blood). Our study underscores the complex relationship between malaria transmission, prevalence rate and the dynamics of malaria episodes. A better understanding of local contextual determinants, including the effect of agricultural activities, will help to improve the local epidemiology and control of malaria.

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.