According to a recent WHO report, Nigeria has one of the highest malaria death rates in the world. To save lives, NGOs must go further than just distributing mosquito nets
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In Nigeria the lack of use of mosquito nets is blamed for the spread of malaria, one of the leading causes of child deaths. Photograph: STEPHEN MORRISON/EPA
In Sokoto, Nigeria on a chilly December morning, the state government launched an effort to distribute 2.5 million insecticide treated mosquito nets (ITNs) to households across the north-west corner of the country. This distribution represents the last of nearly 58 million free long-lasting insecticide-treated nets handed out across the nation between 2009 and 2013.
International donors including the Global Fund to Fight Aids, Tuberculosis, and Malaria, World Bank, the UK's Department for International Development and the US's President's Malaria Initiativehave played a significant role in scaling up malaria prevention in Nigeria.
But as Bill Brieger of Johns Hopkins University wrote in his blog Malaria Matters: "Having nets 'in place' and having nets 'used' are two different indicators of success. A major weakness of past public health programming has been providing people with technologically sound and useful interventions without taking into full account the social, cultural and behavioral factors that influence acceptance and use of the interventions."
The proportion of households owning one or more ITNs in Nigeria increased from 8% in the 2008 Demographic and Health Survey (DHS) to 42% in the 2010 Malaria Indicator Survey (MIS) and the proportion of children under five years reported to have slept under an ITN the night before the survey increased from 6% in the 2008 DHS to 29% in the 2010 MIS.
Progress, yes, but certainly not enough. According to the MIS, the most common reason why no one slept under the net was that it was too hot. A smaller percentage of households said the net was too difficult to hang, the net was not needed or there were no mosquitoes. While a review of 59 articles published in Malaria Journal cited inconvenience, comfort, problems with hanging nets, lack of space and low awareness of need as reasons for not using nets.
Demand, however, appears to be on the upswing. We heard that in Sokoto during a recent polio vaccination campaign some mothers refused the vaccination when the stock of mosquito nets ran out. They had been promised free nets with the vaccination. In the end they received vouchers that could be exchanged for nets.
So how do we engage more effectively with communities to increase net usage? Last June at a behaviour change evidence summit organised by the United States Agency for International Development (USaid) and Unicef, partners reviewed evidence in order to better understand how to improve child survival. The evidence reveals progress and opportunity in some areas, and significant gaps in others. It suggests interventions designed to increase the use of health services and community-based messages encourage behaviour change.
Evidence also demonstrates the great potential of new information and communication technologies in strengthening the capacity and skills of health workers, and encouraging treatment. Community participationand knowledge remain main drivers to increase demand and use of ITNs. The culture of malaria prevention must become part of the fabric of life in every community.
"Provision of nets alone will not bring about high coverage in Nigeria. We need to create the demand for insecticide treated nets and for malaria control services, and that has to be done by raising awareness of malaria and community knowledge about the most effective means of preventing and treating it," said Dr Folake Olayinka, director of Support to National Malaria Programme, a partnership between Nigeria's National Malaria Control Programme and other malaria control agencies, led by Malaria Consortium.
Another step is to more effectively mobilise communities and organisations inspired by faith to advance the welfare of children and mothers. In Nigeria, traditional leaders are often on the front lines of changing behaviour. The World Faiths Development Dialogue notes that the Nigerian Interfaith Action Association (Nifaa) is engaging more than 15,000 imams and pastors in communities to speak to their followers about malaria prevention and treatment. The success of NIFAA's work has won support from Nigeria's National Malaria Control Programme and the World Bank.
Another medium of communication on this subject is radio, which is very popular in Nigeria. In three focus group interviews in Sokoto last month, three-quarters reported hearing stories on malaria prevention and treatment on the radio. In a review of Voice of America's broadcasts, malaria prevention messages were clear but often very technical and not very personal and relatable. Analysis of twelve 30-minute episodes of the programme Karamin Sani Kukumi Ne (Little Knowledge is a Danger) over a 12-month period, showed 11 discussions of polio, but only five on malaria. We must become far better at crafting persuasive narratives that trigger an emotional response among listeners, increase frequency and diversify the messenger.
In a paper for the American Journal of Tropical Medicine and Hygiene, Carlos C Campbell and Richard W Steketee wrote that the path to the elimination of malaria must include community involvement and ownership, local and national willingness (including growing domestic funding) to persevere until the task is complete, and unwavering global support.
Back in Sokoto, as families receive nets, we are making progress, but we are still a long way from ensuring that parents take full advantage of simple steps and tools to protect their children.
