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The role of community education and involvement in malaria control
To advance in the battle against malaria, not only de we need new tools and techniques but also better ways of applying all available tools and techniques in unison to attain the strongest synergistic power possible under various local conditions. Integrated Vector Management (IVM) has been a hot topic for some time now, yet it is far from reaching its full potential in many malaria endemic areas. A lot of the attention off IVM has been focused on the combined use and improvement of the tools and techniques available to formal malaria vector control programmes that that is backed by technical and financial resources. With a lot of focus on big interventions and new products, small, basic and less glamorous interventions are often neglected.
The role and importance of community involvement is often over-looked and under-utilised in control programmes. Many malaria programmes focus on providing the communities with vector control interventions in the form of indoor spraying and / or bed-nets, and these interventions are provided to the community free of charge and without expecting any action on the part of the community apart from allowing spraymen into their homes and removing some furniture and foodstuff from their dwellings. Malaria awareness campaigns are often restricted to providing information at health posts and through the media (television, radio and printed press) however these media are not readily available to all people in rural areas and to people with low levels of education. These campaigns are also usually aimed at informing people about vector control activities, and to motivate people to make use of the provided control measures, with little focus on actions that individual community members can take to not only help themselves, but to help the overall effectiveness of the local malaria control interventions.
These practices often results in a culture of dependency, where the affected people in rural areas are in most part dependent on the formal control programmes to provide all protection against the vector mosquitoes. In many cases the perception of the local people is that they don’t have the resources or knowledge to actively participate in malaria control. However, when visiting these villages, one often sees a variety of risks that can be easily rectified by local inhabitants with little or no resources. One good example is the many small puddles of standing water often encountered in and around rural villages in the rainy season. These can easily be filled in by nearby householders or even children at no cost, and often without the need for any tools at all. These puddles are often not perceived as a thread by local inhabitants, yet hundreds and thousands of vector mosquitoes can hatch from them, not only increasing the malaria risk, but also contributing to the nuisance factor. Another simple example is the inappropriate use of bednets . . . a million bednets won’t make a difference if a large percentage of the nets are used inappropriately.
The lack of accurate knowledge at community level also results in problems such as negativity towards certain insecticides and increasing refusal to indoor spraying, which in turns affects coverage rates and thus the protective value of IRS programmes. It is not only vector control activities that are affected, for instance, with Malaria rapid tests resembling HIV rapid tests, uninformed individuals may be sceptical of “getting tested”. Fear of the unknown and poorly understood can severely hamper the effectiveness of good control measures.
As the age-old saying goes...”Knowledge is Power” and to get the community motivated and involved will require educating the communities to such an extent that they will not solely be reliant on formal programmes to protect themselves from mosquito borne diseases, but will actively participate in anti-malaria activities, contributing towards true integration of all resources. By educating the communities in areas plagued by malaria, and getting them actively involved, we can increase the global “Army” fighting against malaria by millions.
Dear Anton
Thank you for your reply and some compelling reading. I found the story of Dr. Kligler and his achievements both encouraging and fascinating. It is amazing how the “hopelessness” of a situation can start changing with a change in people’s attitude. Quite interestingly, community education was valued almost as much as the practical results obtained in the campaign. Dr. Kligler acknowledged the contributing role of human behaviour (carelessness and neglect) in the malaria scourge, as well as the fact that every situation warrants investigation to ensure the systematic implementation of the most appropriate control measures. It would be interesting to find out more about the methods that was devised and used to establish malaria control on an extensive scale at low cost where no money was available for drainage projects.
Great parts of Africa are faced with a similarly “hopeless” malaria situation that is deepened by the spread of insecticide and drug resistance, scarcity of capacity and lack of financial resources for extensive modern malaria control. Dr. Kligler’s strategy may well be worth some pondering if we are to claim Africa back from malaria!
Andre
Dear Andre,
Thank you for your reply of 8th May.
I have just entered a blog today "How was malaria of 100 years ago eradicated in Palestine/Israel? And without vaccine?" and which includes a link to the scanned book of Dr Kligler which I have just organised. I hope this is of interest and of use.
Anton.
I am happy with your input on community education which seem to be the missing link in the fight against malaria. Though I would rather you called it community participation, since every tropical community is aware of malaria and have their own modest way of controlling it. That is why the disease has not wiped out our communities.
Community knowledge is available in every community and should be fully utilized. The direct participation of local people would by now.have revealed local formulas or ideas about malaria control which could easily be developed into remedies. I know that in my part of Nigeria, orange peels have been used as mosquito repellents for a long time, while nets have met stiff challenges because of our hot weather.
That is where the study of participatory communication comes into view. I believe every change facilitator should acquaint himself with this new area. The idea of education and information should give way and the fight against malaria should involve communicators beyond just medical and health professionals.
Suleiman Haruna
The Malaria imperative
Nigeria
Dear Suleiman
I appreciate your feedback. I agree that all affected communities know about malaria and make use of traditional methods for control or prevention. Some of this traditional knowledge and methods may even be developed further to great value in the global fight against malaria. However, local knowledge is often incomplete, and may contain inaccurate facts on the disease and how it works. By correcting false information/beliefs and improving their malaria knowledge, affected communities will become better equipped to actively participate in the fight against malaria. Improved knowledge could also lead to the better utilization of appropriate traditional methods against malaria, and with the sharing of information on successful control methods.
Andre
When I taught in a school in Nigeria in the 1960s we had a group of boys who were enthusiastic to help with work in a school for the blind and other charities. It is a pity that youth organisations such as Scouts and Guides do not seem to take much interest currently in helping with problems such as malaria. Although one or two groups have, reportedly, assisted in distributing bednets, the senior staff who run these organisations nationally and internationally have shown no interest in encouraging these young people. If "Community involvement" means anything it should include all sections of society.
Dear Geoff
I absolutely agree that all sections of society should be included under community involvement. The enthusiasm and energy of children could be harnessed in various ways to benefit the fight against malaria. Schools and educators can play a vital role in mobilizing children to participate in small community based source reduction projects etc. Similarly, Children may be used to improve community wide malaria knowledge through educational plays. Who knows what clever ideas kids may come up with?
Andre
What are some of the ways of encouraging community involvement?
I am working with a partner in western Kenya. We are a small operation, just a team of two people. My partner lives in Kapsabet, Kenya, and I live in New York City, USA. Kapsabet is a small town in an district where there is endemic malaria, but I don't believe malaria is a problem in the town itself because of its elevation. Outside the town, it is more of a problem.
Is it possible for one person in a town to spark local interest in fighting malaria? How might one encourage local volunteering and local fundraising activity?
Cliff
Dear Cliff
I am confident that a single person can spark local interest in fighting malaria by starting small and growing from there. Maybe a good starting point would be to reach out to community leaders to assess their knowledge, believes and needs in terms of fighting malaria, and to discuss the possible roles that the community may play.
I am sure that there are many Malaria World members that may provide much better advice from experience, and would encourage them to share their thoughts on the matter.
Andre
Great work done Andre for the post. I strongly support your strategies of community education and involvement. I am the National Coordinator for Osagyefo Network for Rural Development (OSNERD), a rural-based non-governmental organization in Ghana. The organization last year implemented a malaria eradication project that concentrated on community education and involvement of the risks of malaria.
OSNERD has realized that bed-nets and anti-malarial drugs do not facilitate the total eradication of malaria vector parasites. What is needed is to take hold of the issue of education of rural settlers in remote areas in Ghana for them to understand the necessities of environmental cleanliness.
We embarked on massive education and community clean-up exercises. After the completion, OSNERD formed volunteers that still keep the project running. We sprayed stagnant waters and desilted gutters and areas that served as breeding grounds for mosquitoes.
We are bent on expanding this strategy this strategy when we get the needed funding.
I am really impressed with that strategy you have put forward and I hope we will all expand and totally eradicate malaria.
Malaria is draining the economies of Africa and destroying lives and stagnating development. We must act now and smart. Bed-nets, anti-malarial drugs are not the best method to eradicate.
OSNERD seeks partnership to make the project "Kusi Environmental Initiative" massive. KENI is still in its implementation stage and needs the support of all.
Dear Stephen
Thank you for your response! I must applaud you and everybody involved in the Kusi Environmental Initiative for taking on this challenge. I believe that allowing the community to take some ownership of a project will make a difference in the attitude towards, and acceptance of, projects initiated in their area. I am hopeful that his project will grow in leaps and bounds, and that you will soon be able to share great success stories with us! Environmental cleanliness will not only contribute towards the reduction of malaria vectors but also help reduce other insect and rodent pests.
Please share the experiences, progress and lessons with us as the project grows!
Andre
Congratulations Andre,
I applaud your reminder that people are good at helping themselves. In Niger, Prof El Tahir and Arne Bomblies of MIT showed that filling small pools around villages with An gambiae problems would be an effective method of malaria control (Bomblies et al 2008 Hydrology of malaria, Water Resources Research 44W12445).
Before spraying inside of houses in Angola, we conducted extensive community explanations, and ask for help in removing furniture before spraying. Happily this resulted in 98% acceptance of our spray teams (Jobin 2010 A realistic strategy for fighting malaria in Africa, Boston Harbor Publishers).
In the Blue Nile Health Project in central Sudan we formed village health committees, usually led by a school teacher or the nurse, with lots of eager students. They started with general sanitation campaigns and then added drainage etc as the rains came (El Gaddal 1986 Blue Nile Health Project, J Trop Med Hygiene v68(2).
Do you speak from experience in Africa? It would be good to publicize any work you have done on malaria so that others can learn.
Bill Jobin
Blue Nile Associates
Dear Bill
Thank you for the positive reply.
My current experience is from work in Southern Mozambique as part of a regional malaria control programme, about which I will hopefully post more soon. Through mostly informal conversations with local health workers and malaria control programme staff, I have gained the impression that many of the stumbling blocks (like IRS refusals) encountered by control programme staff is related to a lack of knowledge or mis-information under the local population. I am of the opinion that this situation can be remedied through a well thought out educational plan aimed at people with greatly differing levels of education.
In some areas I have come across active breeding sites (harboring Anopheline mosquitoes) in the mids of rural and peri-urban settlements. Nearby residents did not connect these "insignificant" puddles of water to malaria risk. These are usually breeding sites that could easily have been filled in or treated by local inhabitants with the appropriate knowledge.
Maybe a last comment... African people are notorious for coming up with ingenious solutions to various problems, utilizing the limited resources available. We may well be surprised at the solutions forthcoming from the local inhabitants if they have a better understanding of the problem at hand.
I read your article of 2nd February 2011 with great interest. I have just finished the research and created a website www.eradication-of-malaria.com dealing with the eradication of malaria in Palestine/Israel which began in 1921/1922. The scientist behind the first successful national method was a Dr I Kligler who died in 1944, and seems to have been since forgotten. Malaria was eradicated in Israel in 1967. Dr Kligler's methods were recognised in his lifetime by the Malaria Commission of the League of Nations in 1925 when the Commission went to inspect the eradication works in Palestine, and he eventually became a member of the Commission. The League of Nations concluded their 1925 report after the inspection with the words that the men who carried out these works 'can be regarded as benefactors not only to the Palestinian population but to the world as a whole'.
The 1925 Report contains the Ordinances introduced by the British Mandate to ensure co-operation and compliance by the population with the procedures and methods employed by the scientists.
Palestine 100 years ago was 'soaked' in malaria, and the British Mandate even referred in 1918 to the position as 'hopeless' from the malaria point of view. You can see the severity of the disease on the above website, and you can then appreciate what a daunting task was given to Dr Kligler to rid the area of malaria. He wrote in 1925:
'Very little personal investigation of Palestine was necessary to convince me ... that unless something was done to check the ravages of malaria, the reconstruction of Palestine would be a costly if not altogether an impossible effort. How to approach the problem was a more difficult matter. The local view was beautiful in its simplicity. It ran somewhat as follows: You can get rid of the malaria only by extensive drainage; extensive drainage will require enormous sums of money; therefore, lacking these enormous sums, malaria cannot be eliminated from the country. QED. But I suspected then, and am now convinced, that even had large sums been available for drainage and the drainage accomplished, the malaria would have been little affected, because mosquitoes breed in little, out-of-the- way unsuspected places, which even the most eleborate systems of drainage will not reach. And at least half of the malaria can be ascribed simply to human carelessnes and neglect.
........
The campaign (of eradication) was carried out along these main lines: (1) Detection and treatment of carriers. (2) Anti-mosquito campaign. (3) Quinine prophylaxis. (4) Education.
First, and perhaps the most important of the fruits of this was the change in the attitude of the population towards malaria. ..... They had come to realise that malaria was a preventable disease. ...... The old indifference is gone. A small outbreak of malaria ... is the occasion for a storm. Investigations are held and the (Malaria Research) Unit is blamed (sometimes justly) for not doing the very thing which only four years ago these same people insisted it was impossible to do.'
Dr Kligler's methods were simple, but he never treated a new set of circumstances automatically as identical to previous circumstances without first investigating. It was time consuming but effective.
I am unsure to what extent you may be familiar with above, but if after seeing the website presentation I can assist with any more information, I would be pleased to do so.
All the best.
Anton Alexander