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Column: Social values & beliefs: the key to successful malaria prevention?

March 23, 2014 - 08:46 -- Ingeborg van Schayk
Do social norms and cost sharing matter in obtaining community buy in and adding value to health commodities? An excerpt from the field with emphasis on community based participatory methods and insecticide treated bed net (ITN) usage.
One cannot barrel down the cracked, steaming tarmac of the M1 in the Southern African nation of Malawi without encountering a billboard adorned with malaria prevention messages. These ubiquitous social marketing campaigns, concocted by nongovernmental organizations, the Ministry of Health and multilateral organizations provide an omnipresent reminder of the need to integrate social acceptance into malaria programming strategies. They are colorful, with bold images of families sleeping together under a bed net, safe from the parasite that lives inside the menacing mosquito buzzing incessantly outside of the protective barrier. They smile while they sleep, depicted as content and healthy. Women carry their wares and produce to the market past these signs, taking note of their relevance.
As any passenger travels through villages, trading centers and cities, she will also notice another poignant indicator of the progress and efficacy of these well-coordinated campaigns. Mosquito nets employed as protective screens for crops of fat, red tomatoes. Nets flung with artistic precision into the Shire River to catch usipa, a small shiny fish, the main source of protein in the Malawian diet. Nets adorning window frames and functioning even as clothing. Any member of a team strategizing malaria control programming is aware that getting people to utilize bet nets is not so simple as providing messages and education related to malaria prevention. 
These messages serve as an essential component of a package of community based interventions aimed at addressing prevention, treatment and resistance management that are culturally acceptable. But we should also be prioritizing incorporating social norms and the idea of adding value to the commodity as a tool in the arsenal for combating this fatal disease that cripples economies and desecrates entire families year in and year out. 
So how do we move towards behavioral uptake and community buy in of insecticide treated bed nets? Many methods have been tried and tested, some with great effect on policy and programming and others leaving researchers and the malaria community at large nonplussed.
A pivotal finding addressing this question came out of a study in Kenya aimed at evaluating the utility of adding a nominal price to insecticide treated nets at prenatal clinics on usage intensity and rationalization of usage. Instead of providing the health tool as public good free of charge as is the prominent method for many Ministry Of Health programs, researchers tagged on a fee to evaluate if in fact attaching a monetary value to the commodity would also increase the women’s perception of the nets actual importance and value.
Many postulated that, as in other scenarios with various products, women would value their purchase because they were required to pay for it, and thus assign increased value to the commodity, ensuring usage. Researchers concluded that this was not the case with the study’s target population in Kenya. In the context, assigning monetary value to ITNs did not suggest an increase in usage of nets for preventing malaria, but did illustrate that it did actually dampen demand for the health tool.
The results provided policy lessons as well as direction on evaluating efficacy in program development:
“No evidence was found to suggest that cost-sharing increases ITN usage: women who paid positive subsidized prices were no more likely to use nets than those who received ITNs for free…Overall, given the large benefit to the community associated with widespread usage of insecticide-treated nets, results suggest that free distribution of ITNs is both more efficient and more cost-effective than cost-sharing.” (Cohen & Dupas, 2010).
This analysis serves as an example for the obvious need to formulate programming that increases demand and proper usage simultaneously. But the “how” of actually to achieve this ideal outcome is still elusive, decades after the World Health Organization included ITNs as part of the essential package in the fight against malaria. In conjunction with diagnosis, effective treatment and indoor residual spraying, ITNs decrease mortality and morbidity related to malaria and avert 50 percent of cases via protective efficacy (Clarke et al. 2001).
So how can we ‘add value’ if not by employing a cost sharing scheme as was tested in Kenya? In my work with communities and various entities in Africa and Latin America and Caribbean regions, a key component of any successful intervention involving health tool usage surfaces, despite discordant contexts. A common theme in the design of the intervention is integration of social and behavioral aspects related to malaria (or any focus content) into the program. By involving both the target population and local leaders in designing program components, we employ community based participatory methods, essential in many grass root efforts to achieve gains in public health, agriculture and economic development. Often in the effort to design programs that are broad reaching and translatable into many contexts, we forfeit the programs’ impact by negating culturally relevant interventions.
There are many well explored facets of perception surrounding the use of ITNs related to fertility, cleanliness and health in communities. But there are often surprising, unexpected aspects of culture and belief systems that function as barriers to employing any health tool. Sometimes the factors are unknown to both to local and foreign organizational members, and play a huge role in the success or failure of a program.
An anecdote from a program in Malawi aimed at evaluating the effectiveness of ITNs in preventing malaria illustrates this point. A massive coverage campaign had recently been completed in the program’s catchment area. Community outreach agents were working to promote adherence, provide education and performmonitoring of the program. In a particular community, the uptake and usage was extremely low, compared to the surrounding communities.
Our colleagues worked closely with the villages’ chief, traditional authorities and community health agents to ascertain why specifically people in this community were averse to sleeping with the bed nets provided by the coverage campaign. People were reluctant to give information, and after community sensitization did not yield results, the stakeholders sat down for a sort of reconnaissance mission. Finally, the chief revealed the problem. It was the shape of the nets conflicting with religious beliefs widely held by the citizens of this particular village that precluded their adoption into homes and sleeping spaces.
The chief patiently explains as we all sit together on the woven mat out the front of his house, surrounded by baobab trees and curious children. “People in my village have been receiving assistance for malaria for many years,” he begins. “But always we are given the nets shaped like a triangle. This time, we were given the ones that are in the shape of the boxes we use to bury our dead. How can we go to sleep, under the container for a corpse?” 

A collective exhale from our group; our Malawian and foreign colleagues alike did not anticipate shape as a barrier in using the nets. Something as simple as planning for the shape of the actual net delivered was not taken into consideration, simply because everyone was operating under the assumption that it was supplying the net to the individual household and maintaining adherence to proper net usage that would be the challenge in decreasing transmission.
“But sir, why did you not tell us?” a colleague cautiously ventures while maintaining respect for the chief’s position. “Very simple,” the chief replies, the tone of the Buddha resounding in his answer, “you did not ask”.
By simply “asking” about social and cultural beliefs surrounding mosquitos, nets, religious beliefs, social norms- we can build strong programs that are tailored specifically to communities that we are trying desperately to reach. To achieve progress in decreasing the global malaria burden, we need to actively engage communities in participatory methods, and take into account nuanced variants based on things we can later anticipate in program design, implementation and evaluation. Nuances like the shape of a bed net, for example.
I am looking forward to discussing other’s experiences with participatory methods, adding value and culturally appropriate global health interventions on this forum.
A hard learned lesson from the program in Malawi leads me to open the virtual floor here to encourage discussion on what it means to simply “ask” and engage.
The opinions expressed in this column are those solely of the author and do not reflect those of the author’s current or previous professional affiliations.
Cohen, Jeesica and Pascaline Dupas, 2010. Free Distribution or Cost-Sharing? Evidence from a Randomized Malaria Prevention Experiment. The Quarterly Journal of Economics,125(1): 1-45.
Clarke S.E. et al., 2001. Do untreated bed nets protect against malaria? Transactions of the Royal Society of Tropical Medicine and Hygiene, 95: 457-462.

Kate Dieringer RN, BSN, MPH worked as a technical advisor for the Malaria Alert Center/Centers for Disease Control and Prevention (College of Medicine, Malawi) providing support for malaria programming and operational research initiatives in Malawi. Her background combines global health and emergency/trauma clinical services. She is invested in malaria prevention and control through community based partnerships, as well as health systems strengthening and investment in human capacity. Kate’s scope has focused on Latin America and the Caribbean and Africa regions involving HIV, malaria and maternal child health programming. Currently, she is working with Partners’ in Health Haiti on capacity building and clinical program implementation.



William Jobin's picture
Submitted by William Jobin on

Hi Kate,

Thank you for recounting your experience with promotion of treated bednets in Africa. I think part of the problem might be that most folks have a different perception of bednets than do the WHO and USPMI people who have adopted them in the global strategy.

If you have used bednets very often you will agree that they are almost intolerable during the hot and humid months of the malaria transmission seasons. I learned this early on while working for CDC in the Caribbean in 1960. Adults, and even older children, will simply not sleep under them if they are sweating buckets. Rather they will go outside where there is a breeze.

Howevr infants have no choice, if their mothers put a net over them while they are sleeping. So I think it would be good to recognize that bednets have a limited role in the overall strategy of suppressing malaria, especially in Africa.

Adults and older children need metallic screens on windows and doors, closure of eaves and other openings instead of the intolerable bednets. Even then, if there is not enough electricity for a small fan, many people will chose to sleep outdoors and take their chances.

So you might also considering asking people if they think bednets are worthwhile.


pass the information back up the line to the folks in Geneva and Washington and Atlanta, so that they learn too!


William Jobin Director of Blue Nile Associates

Guy Reeves's picture
Submitted by Guy Reeves on

With respects to your question of 'why not ask' I suspect that a implicit assumption of programs aimed at avoiding or managing diseases which can be devastating is that in a significant proportion of instances individuals and communities will adapt their values and customs when they perceive the enormous benefit. Furthermore, having the majority adapt, rather than continually adapting the program, saves limited resources so a larger numbers of people can be covered.
I would be interested to know what you thought of this naive speculation.

Do think a strategy of starting with 'one one size fits all' + monitoring efficacy and only going back to ask problematic groups is likely to be the most efficient strategy? Or are there circumstances where ask everybody first might be efficient?

MPI, Plön (Germany)

Submitted by Kate Dieringer (not verified) on

Thanks Guy for your insightful comment! To clarify, the essence of the article was meant to illustrate the need for attention to the cultural, contextual and social realities of target populations in program design and implementation by employing participatory methods of design. In this specific case, we were running a 1000 household, insecticide treated net efficacy study (not a multi-country intervention). Regardless of a program's details, efficiency is of course paramount. But we often sacrifice quality, efficacy and adaptability with these one size fits all approaches. Perhaps organizationally we can re frame our perspective and examine these "problematic groups" as leads to discovering solutions. We can then attempt to broaden our shared successes by creating efficient and appropriate interventions, research methodologies and programs. In retrospect, it was our program design that failed the 'problem group' not the problem group that didn't adhere to our prescriptions.

Guy Reeves's picture
Submitted by Guy Reeves on

I think it is clear from the article and Kate's follow up what she is saying about the value of adaptability, asking and listening

I know it is a bit nerdy but I see a number of parallels with this and what is called 'agile software development'. This is a very current method, developed in response to large technology projects which have a high fail rate in part due to their tendency to become inflexible (often resulting in massive waste of resources and time).
Agile programing even has a manifesto which includes

Individuals and interactions over Processes and tools
Customer collaboration over Contract negotiation
Responding to change over Following a plan

I am sure that the same sentiments have probably been represented in many past and present buzzwords and that some of the wording is not exactly applicable to disease control, but I am curious if anybody sees anything interesting here?

If anybody is interested you can read more about the philosophy behind agile programs at

I wonder if what i described as "rolling wave " planning is a form of what Kate advocates.

By the way, in the village Kate mentioned in the article that expressed a preference for triangular nets, did everything workout once they were provide?


MPI, Plön (Germany)