The Human Element

For every 1,000 children who sleep under insecticide-treated bed nets, 5.5 lives are saved. Yet some 20 percent of people who own nets don’t regularly use them as protection from malaria because they find the nets hot and inconvenient, or because they don’t see mosquitoes around.

Rapid tests reliably diagnose malaria in 15 minutes. Yet some health workers who perform the tests are skeptical of their accuracy and instead rely on their own judgment to diagnose malaria.

Artemisinin-based combination ther-apy (ACT) is known to be highly effective in treating malaria and countering drug-resistant forms of the illness. But as many as 50 percent of patients don’t seek malaria treatment from public clinics, and the ACT drugs available from private medicine shops may be ineffective because they are counterfeit, expired or of poor quality.

The fight against malaria is a complex one, and it’s complicated by the fact that the malaria parasite doesn’t just attack the body: It preys on human behavior and the mistakes we make. People don’t consistently make full use of the tools available to protect themselves from malaria, nor do they provide or seek effective treatment in a timely fashion, even when they know they should.

“There’s this idea that we can’t eliminate malaria without a vaccine,” says William Brieger, DrPH ’92, MPH, a professor in the health systems program in the Department of International Health at the Bloomberg School and a senior malaria specialist at Jhpiego. “An effective vaccine would certainly help—we always need new tools. But if we are not even fully using the technology we already have, then we won’t control malaria.”

Access to long-lasting insecticidal bed nets (LLINs) is still an issue in many parts of the world, but large-scale distribution campaigns over the last few years have proved successful in getting hundreds of millions of free nets to people in Africa who need them. However, just distributing nets isn’t enough, says Matthew Lynch, PhD, director of the Global Program on Malaria at the Center for Communication Programs. “Nets don’t work if people don’t use them.”

Some Africans say they don’t use nets because the sleeping areas in their small homes double as living areas during the day, and the nets are inconvenient to put up and take down, says Lynch, who directs the NetWorks Project at CCP, which was founded in 2009 and funded by a five-year cooperative agreement for up to $100 million from USAID. There are also people who avoid the nets during the dry season when mosquitoes are less prevalent. That’s a dangerous mistake to make, Lynch notes. “At the beginning of the dry season the mosquitoes that are around are older and more likely to be carrying malaria,” he explains.

CCP is involved in a number of messaging campaigns around the world to help people understand why they need to sleep under LLINs. In Senegal, for example, people are being urged through TV, radio and interpersonal communication to follow the “Trois Toutes,” or “Three Alls,” and have “all your family members under a net, all nights of the year, all year round.” A successful campaign in Tanzania featured poignant two-minute interviews with national leaders whose loved ones had died of malaria. “One of the key factors for effective communication is ensuring all of the channels reinforce each other,” Lynch says.

Brieger, who has spent decades studying tropical diseases and human behavior, emphasizes that it’s not just potential victims who make mistakes when it comes to malaria prevention and treatment. Policymakers, health providers and others in the system also bear responsibility for making high quality and affordable services available.

 It’s because of the lack of FDA-type agencies in some countries that counterfeit or poor quality ACTs can slip into the supply chain. It’s poor communication that leads health workers in some antenatal clinics in parts of Africa to place pregnant women at added risk for malaria by withholding free bed nets until after they have completed preventive treatment; by using the nets as an incentive to increase antenatal care, these health workers endanger the women and their unborn children. And in Burkina Faso, some health workers second-guess the results of rapid diagnostic tests for malaria, thereby leading to misdiagnosis of patients.

“We need to look at the behavior of service providers, of policymakers, of everybody,” says Brieger. If workers at health centers, the district level or even higher up “won’t provide the services, funds and commodities needed, you can’t blame [consumers] for not doing the correct thing,” he says.

Educating health care workers can have a significant impact on the care patients receive, he says. When workers in rural western Kenya were trained in the use of intermittent preventive treatment for malaria in pregnant women, their delivery of this treatment to community members improved. “Health care workers have misconceptions that may inhibit their provision of these services, and training is one intervention that can help them perform better,” Brieger explains.

Lynch hopes that as bed nets become more widely available, more people will use them consistently. He’d like to see a cultural change, wherein providing nets for your family becomes as much of a habit as providing food or clothing.

Still, he recognizes that even people with the best intentions can be unreliable—and that for most of us it is easier to talk about changing behavior than it is to actually change it.

“Nets are not always easy to use and they require discipline and a consistent habit. That’s hard to do,” he says. “How many of us have sworn that we were going to floss every day or stick to our exercise regimens because we know it’s good for us … and yet we still don’t do it?”