Equal Opportunity, Equal Work: Increasing Women's Participation in the U.S. President's Malaria Initiative Africa Indoor Residual Spraying Project

BACKGROUND

One of the primary control measures for malaria transmission is indoor residual spraying (IRS). Historically, few women have worked in IRS programs, despite the income-generating potential. Increasing women's roles in IRS requires understanding the barriers to women's participation and implementing measures to address them. The U.S. President's Malaria Initiative (PMI) Africa Indoor Residual Spraying (AIRS) Project is the largest implementer of IRS globally. To address gender inequity in IRS operations, PMI AIRS assessed the barriers to the participation of women and developed and implemented policies to address these barriers.

METHODS

The PMI AIRS Project initially identified barriers through a series of informal assessments with key stakeholders. PMI AIRS then implemented a series of gender-guided policies, starting in 2015, in Benin, Ethiopia, Ghana, Mali, Madagascar, Mozambique, Rwanda, Senegal, Zambia, and Zimbabwe. The policies included adapting physical work environments to ensure privacy for women; ensuring the safety of women in the workplace; guaranteeing safety and job security of women during pregnancy; and encouraging qualified women to apply for supervisory positions. The project collected routine programmatic data on staff, spray quality, and spray efficiency; data from 2012 through the end of 2015 were analyzed (up through 1 year after implementation of the gender policies). In addition, PMI AIRS conducted surveys in 2015, 2016, and 2017 before and after the spray campaigns in 4 countries to determine changes in gender norms among spray operators through questions about decision making and agency.

RESULTS

The PMI AIRS Project increased women's employment with the program. Specifically, women's employment increased overall from 23% in 2012 to 29% in 2015, with a 2015 range from 16% (Mali) to 40% (Madagascar). Growth among supervisor roles was even stronger, with the percentage of women in supervisory roles increasing from 17% in 2012 to 46% in 2015, with a 2015 range from 9% (Mali) to 50% (Madagascar). While the data showed that in most countries women sprayed fewer houses per day than men in 2015, the differences were not meaningful, ranging from 0.1 to 1.2 households per day. Gender norms shifted toward more egalitarian views in 2 of the 4 countries with survey data.

CONCLUSION

Preliminary results suggest the PMI AIRS Project gender policies are increasing the engagement of women in all aspects of spray operations, especially in supervisory roles. Expansion of these policies to all countries implementing IRS and to malaria control implementation more broadly is recommended.

Feasibility and Effectiveness of mHealth for Mobilizing Households for Indoor Residual Spraying to Prevent Malaria: A Case Study in Mali

Sending voice and/or text messages to mobilize households for spraying was more costly per structure and less effective at preparing structures than traditional door-to-door mobilization approaches supplemented with radio and town hall announcements. Challenges included:

Lack of familiarity with mobile phones and with public health mobile messaging

Lack of face-to-face communication with mobilizers, making it easier to ignore mobilization messages and preventing trust-building

Low literacy levels

Gender differentials in access to mobile phones

Components of mHealth are increasingly being added to development interventions worldwide. A particular case of interest is in Mali where the U.S. President’s Malaria Initiative (PMI) Africa Indoor Residual Spraying (AIRS) Project piloted a mobile mass-messaging service in Koulikoro District in August 2014 to determine whether voice and/or text messages received on cell phones could effectively replace door-to-door mobilization for an indoor residual spraying (IRS) campaign. To measure the pilot’s effectiveness, we evaluated structure preparedness (all household and food items removed) in 3 pilot intervention villages compared with 3 villages prepared for spray through door-to-door mobilization that was modified by incorporating town hall meetings and radio spots. Structure preparedness was significantly lower in households mobilized through the mobile-messaging approach compared with the door-to-door approach (49% vs. 75%, respectively; P = .03). Spray coverage of targeted households also was significantly lower among the mobile-messaging villages than the door-to-door mobilization villages (86% vs. 96%, respectively; P = .02). The mobile-messaging approach, at US$8.62 per structure prepared, was both more costly and less effective than the door-to-door approach at US$1.08 per structure prepared. While literacy and familiarity with technology were major obstacles, it also became clear that by removing the face-to-face interactions between mobilizers and household residents, individuals were not as trusting or understanding of the mobilization messages. These residents felt it was easier to ignore a text or voice message than to ignore a mobilizer who could provide reassurances and preparation support. In addition, men often received the mobile messages, as they typically owned the mobile phones, while women—who were more likely to be at home at the time of spray—usually interacted with the door-to-door mobilizers. Future attempts at using mHealth approaches for similar IRS mobilization efforts in Mali should be done in a way that combines mHealth tools with more common human-based interventions, rather than as a stand-alone approach, and should be designed with a gender lens in mind. The choice of software used for mass messaging should also be considered to find a local option that is both less expensive and perhaps more attuned to the local context than a U.S.-based software solution.