Introducing Insecticide Treated Mosquito Nets in the Kilombero Valley (Tanzania) : Social and Cultural Dimensions

Malaria remains one of the most important causes of suffering, death and poverty. The provision of prompt diagnosis and treatment should be a key component of any malaria control programme, but in reality disease management is often not adequate due to weaknesses in the health systems. Especially in areas, where access to health services and proper medication is limited and where parasites have become resistant to anti-malarial drugs, insecticide-treated nets (ITNs) present an attractive option to complement the other tools in malaria control. Under trial conditions, ITNs have been shown to have an impact in reducing clinical malaria episodes and related mortality. A large-scale social marketing programme has implemented ITNs to reduce child mortality in an area of intense, perennial malaria transmission in southern Tanzania. The present study formed part of this programme. It examined social and cultural aspects of the distribution, delivery, acquisition and use of ITNs, paying particular attention to local knowledge and practice, interactions between project staff and villagers and to household dynamics. The main goal of this qualitative research was to contribute to the improvement of the intervention process within the framework of the Kilombero Treated Net Project. Fieldwork was carried out in two stages: 1) formative research and 2) ethnographic monitoring. Formative research began with a community study in 18 villages from July to August 1996. More contextualized information on local knowledge and practices about malaria, treatment and prevention was collected during a short ethnographic study in two villages between September and December 1996. Based on the findings from the community study and the focused ethnographic assessment, a questionnaire was developed for a survey in four villages. The second stage, ethnographic monitoring, was designed to capture the interactions and social processes surrounding the project implementation in one particular locality over a period of time. An important finding of this study is that people have integrated ideas derived from biomedical knowledge into their interpretation of malaria. Villagers commonly use the term maleria but only to refer to a mild and easily cured type of fever which they see as caused by mosquitoes. Swahili terms such as degedege (convulsions), bandama (enlarged spleen) and homa kali (high fever), on the other hand, are used for conditions that are commonly feared as life threatening, especially for small children, and - from the biomedical perspective - related to the complicated forms of clinical malaria. The local interpretations of malaria and related illnesses are closely linked to the logic of actions taken in specific situations, for instance, since severe forms of malaria are linked to "supernatural" causes, identified as attacks of witches and bad spirits, an amulet (hirizi) from a traditional healer is thought more desirable than an ITN for protecting (kinga) a vulnerable child. In this context, the promotion of ITNs as an effective preventive tool may not make much sense from the villager's point of view. The findings further show that the local understanding of malaria transmission in the study area acknowledges the mosquito-malaria link. Moreover, most villagers (52%) already had untreated nets and insecticide net treatment was not a new idea in the study area. Although the majority of villagers (76%) are aware of the role of mosquitoes in malaria transmission, they seriously doubt the link between severe malaria and mosquitoes. An often heard argument was: If mosquitoes caused severe maleria, everyone would be dead by now. Why would vulnerable young children who live in the village and get bitten by mosquitoes continue to survive? And why would malaria attack people who sleep under nets in a similar way as those who do not? These findings clearly show that researchers should not conceptualise people's knowledge about malaria and its prevention as something that is there, that belongs to a cultural tradition and remains the same over time, in other words, as something static. The knowledge which informs villagers' practices relating to malaria is a result of the interaction of diverse strands of knowledge from different sources. Moreover, people's questions and arguments demonstrate that they do not just have but that they do seek knowledge. On a more theoretical level, knowledge can be seen as a result of interpretive practices. Such an understanding of knowledge has great potential for the planning and implementation of interventions. This study drew attention to the interface between locally available knowledge and the knowledge brought into the area by the project. Drawing on a typology developed in research on cultural dimensions of development (Mundy and Compton 1995), the study examined processes of social interaction and communication through which knowledge was constructed, negotiated and reinterpreted. The data clearly showed that, in addition to a promotional campaign at the beginning of a project, a continuous dialogue between the project and the villagers is needed to enhance the sustainable delivery, distribution and use of ITNs over time. In the last analysis, an ITN intervention can only be sustainable, if people implement it at the household level. Therefore, an investigation into social and cultural aspects of effectiveness includes an examination of social interactions within and across households. Households play an important role in day-to-day health production. More precisely, it is not the household but different members of a household who produce health; what each of them contributes is, to a large extent, defined by gender. Headship is often used as a proxy for gender relations. This study shows that headship is a meaningful analytical category, it should not be assumed but investigated in particular settings. Moreover, the study argues that headship is closely associated with the acquisition, ownership and use of ITNs. According to the dominant gender model in the study area, the husband provides household necessities, and the wife depends on his good will and economic ability. If women live by themselves or with children and head a household, their own skills to generate income determines their acquisition, ownership and use of ITNs. This study demonstrates that a dynamic view of malaria related knowledge and practice opens innovative lines of inquiry which may contribute to enhancing the effectiveness of ITN interventions

Impact of health research capacity strengthening in low- and middle-income countries : the case of WHO/TDR programmes

BACKGROUND: Measuring the impact of capacity strengthening support is a priority for the international development community. Several frameworks exist for monitoring and evaluating funding results and modalities. Based on its long history of support, we report on the impact of individual and institutional capacity strengthening programmes conducted by the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR) and on the factors that influenced the outcome of its Research Capacity Strengthening (RCS) activities. METHODOLOGY AND PRINCIPAL FINDINGS: A mix of qualitative and quantitative methods (questionnaires and in-depth interviews) was applied to a selected group of 128 individual and 20 institutional capacity development grant recipients that completed their training/projects between 2000 and 2008. A semi-structured interview was also conducted on site with scientists from four institutions. Most of the grantees, both individual and institutional, reported beneficial results from the grant. However, glaring inequities stemming from gender imbalances and a language bias towards English were identified. The study showed that skills improvement through training contributed to better formulation of research proposals, but not necessarily to improved project implementation or communication of results. Appreciation of the institutional grants' impact varied among recipient countries. The least developed countries saw the programmes as essential for supporting basic infrastructure and activities. Advanced developing countries perceived the research grants as complementary to available resources, and particularly suitable for junior researchers who were not yet able to compete for major international grants. CONCLUSION: The study highlights the need for a more equitable process to improve the effectiveness of health research capacity strengthening activities. Support should be tailored to the existing research capacity in disease endemic countries and should focus on strengthening national health research systems, particularly in the least developing countries. The engagement of stakeholders at country level would facilitate the design of more specific and comprehensive strategies based on local need

REG recipient attribution of institution service improvements to TDR.

<p>TDR attribution to the improvement of the institution's services was assessed. Ranking was defined as follows: 1 = none, 3 = moderate and 5 = high.</p

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

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

Analysis of the TDR grants during the 2000–2008 period.

<p>NA not applicable.</p><p>*<b>RTG</b> are awarded to individuals to pursue studies leading to the acquisition of a postgraduate degree (MSc, PhD).</p><p>*<b>REG</b> are intended to facilitate the career development of young scientists returning to their home institutions within 24 months following completion of a graduate degree (MSc, PhD).</p><p>*<b>ISG</b> are intended to provide long-term (three years) support to institution.</p