Kédougou is one of the regions of Senegal most heavily burdened by malaria. PCV Ben Gascoigne and his counterpart, Mamba Camara, decided to speak with members of their community about the amount of money they spent on treating malaria last year – a whopping 3,039,100 CFA/6,078 USD. They hoped to raise awareness of the economic burden of malaria and motivate people to focus on prevention. Community members were impressed by the enormous figure but it was sometimes difficult to conceptualize the real value of such a large number.
To visually represent this figure, shortly after World Malaria Day 196 rice sacks—3,039,100 CFA worth of rice—boldly lined the road between the community market and health post. Trained local youth, the community’s health worker, and local Peace Corps Volunteers demonstrated proper net maintenance, led discussions on the economic impact of malaria (e.g., money spent on malaria medication and consultations that could have been spent on food), and demonstrated how to change square nets to round nets for easy hanging. Participants learned that they could greatly reduce the cost of malaria to their families by sleeping under mosquito nets, seeking early treatment for malarial symptoms, and, for pregnant women, by attending antenatal care visits.
Over seventy community members were exposed to the net maintenance stations and many more were exposed to the rice sack visual display and malaria prevention messages broadcasted through speakers at the health post. Fifty people were trained on how to sew torn nets and 21 nets with 135 holes were repaired. Thirty people were trained in net-washing and 24 nets were washed. Twelve women were trained on how to transform a square net into a round net. After the intervention, all seventy community members developed a deeper, more immediately relevant understanding of the economic burden of treating malaria in their community. Furthermore, all seventy villagers improved their understanding of how to maintain nets and had engaged in a discussion about three simple steps to combating malaria.
Recently, PCV Ben Gascoigne and his counterpart, Mamba Camara, conducted long-lasting insecticide-treated nets (LLIN) maintenance and repair consultations using NetWorks-created informational cards. They noticed community members were most engaged while discussing the money that could be saved by reducing the incidence of malaria (i.e., by sleeping under a properly maintained mosquito net and by seeking early treatment for malarial symptoms). For this reason, Gascoigne decided to calculate the amount of money spent by my community on malaria consultations and medication in 2011 (see Appendix A). He met with the head nurse at his health post to discuss and document the cost of consultations and routine medication prescribed for simple and severe malaria (including paracetamol). This required breaking the costs down by age range to closely match the age ranges recorded in the health registry.
Gascoigne’s community spent 3,039,100CFA on malaria consultations and medication in 2011; though remarkable, this number did not impress the leaders of his village as he had hoped. To better communicate the full weight of malaria’s economic burden, he decided to present the cost in a contextually significant manner: using rice sacks. Specifically, at the time of this project, one sack of rice in my regional capital costs 15,000CFA. Calculating for transportation to his village, the amount his community spent on malaria consultations and medication in 2011 equaled 196 sacks of rice. This was an impressive figure considering one sack of rice feeds approximately one small family for one month.
Gascoigne sought to buy 196 rice sacks to use to visually display to his community how much they spent on malaria last year. This project also immediately preceded the rolling out of the national routine LLIN distribution supported by Networks—a program that will allow Senegalese to buy a LLIN for 500 CFA (approximately 1 USD) at local health structures, and distribute LLINs free of charge to pregnant women at antenatal care visits. Coupled with LLIN repair and maintenance training, and the routine distribution, this visual representation was intended to motivate community members to proactively fight malaria. The message: By sleeping under a properly maintained mosquito net, seeking early treatment for malaria-like symptoms, and, for pregnant women, attending antenatal care visits, villagers can save money; villagers can save rice.
Rice sacks were purchased in Kedougou, Tamba and Dakar, and transported to my village. Gascoigne worked with children in his neighborhood and his counterpart to fill the sacks with dead grass, walk them to the health post and stitch them shut. Leading up the World Malaria Day, he used every opportunity he could to explain to curious villagers the sacks represent how much money they spent at the health post because of malaria in 2011.
On World Malaria Day, three other volunteers, his host family siblings and he lined both sides of the stretch of road from his community’s market to the health post with 196 rice sacks. The rice sacks stretched over 100 meters. They were red, pink, green, yellow, white, and blue; they had interesting images on their sides and came from Thailand, Vietnam, India, Argentina, America, Brazil, Uganda, Pakistan, Romania, and other countries; they attracted attention.
Mamba Camara, the community health worker, operated speakers set up at the health post. He played music and, periodically, spoke about the rice sacks and encouraged villagers to bring their mosquito nets to the health post.
Stations for net sewing, net washing, and demonstrating how to make square nets round were set up at the health post. Previously-coached community youth and PCVs worked together to staff each station. Needles and thread were available at the sewing station. Villagers were shown how to sew holes in nets, or tie knots over areas with many small holes, and then demonstrated their newly acquired knowledge by joining the staffers in repairing the rest of the holes in the net.
Once all of the holes in a villager’s nets were repaired, they moved onto the net washing station. Buckets, water, and peanut soap, also known as ‘ordinary soap’ (soap without added chemicals) were available at this station. Proper washing technique was demonstrated, and participants were taught how to dry, and when to wash, their nets. Participants were then asked to wash their own nets while explaining what they were doing.
After washed nets were hung in the shade to dry, participants were directed to the station demonstrating how to make square nets round. Using a bucket lid or wire, participants were shown how to transform a square net into a round net, making it easier to hang in certain hut and to move between inside and outside. An example net tailored to have a fabric skirt, provided by NetWorks, hung next to the station. This net was intended to illustrate one way in which nets can be gentrified.
PCVs at each station emphasized that sleeping under your net and going to the health post early when you have a fever will save your family money (i.e., rice). Camara and Gascoigne hoped this stunning image of a street lined with rice sacks would attract villagers to the health post and leave a lasting impression of the economic burden of malaria.
|Station Competency||Women||Men||Girls (<15)||Boys (<15)||Total|
|Trained in Net Sewing||24||10||11||9||54|
|Participated in Net Sewing||11||7||1||4||23|
|Trained in Net Washing||14||6||4||6||30|
|Participated in Net Washing||10||5||0||0||15|
|Trained in Net Modification||7||0||0||5||12|
|Participated in Net Modification||7||0||0||0||7|
|Total Participants at HP||24||12||18||22||76|
Table 1. Intervention demographicsfor each competency.
Table 1 notes the attendance at eachstation at the health post, and how many people trained at the stationspracticed their new skill. Participants were broken into four age groups: Womenolder than 15, Men older than 15, Girls 15 and younger, and Boys 15 andyounger. As seen in Table 1, 76 local residents were exposed to theintervention stations at the health post. Of those 76 residents, 54 receivedinstruction on sewing holes in torn nets, and 23 people demonstrated theirnewly acquired competence by participating in sewing nets.
|Owner||Net||Net Age||Width Index Finger -||Two Fingers +||Fist||Fist +||Total Holes||Holes Repaired|
|Male 1||1||2010 Distrib||10||0||1||4||15||15|
|Female 1||2||2010 Distrib||3||8||1||2||14||14|
|Female 2||3||2010 Distrib||3||10||2||0||15||15|
|Female 3||4||2010 Distrib||0||0||0||0||0||0|
|Female 4||5||2010 Distrib||5||3||0||1||9||9|
|Female 5||6||2010 Distrib||0||0||0||1||1||1|
|Female 5||7||2010 Distrib||6||5||5||2||18||18|
|Female 5||8||2010 Distrib||0||0||0||0||0||0|
|Female 6||9||3-5 years||7||12||4||4||27||27|
|Female 6||10||3-5 years||N/A||N/A||N/A||N/A||N/A||0|
|Female 6||11||3-5 years||N/A||N/A||N/A||N/A||N/A||0|
|Female 6||12||3-5 years||N/A||N/A||N/A||N/A||N/A||0|
|Female 7||13||2010 Distrib||0||0||0||0||0||0|
|Female 7||14||2010 Distrib||0||0||0||0||0||0|
|Female 7||15||2010 Distrib||0||0||0||0||0||0|
|Female 8||16||2010 Distrib||3||9||3||2||17||17|
|Male 2||17||2010 Distrib||0||2||1||0||3||3|
|Female 9||18||Not Usable||-||-||-||-||-||0|
|Female 10||19||2010 Distrib||19||2||1||1||23||14|
|Female 10||20||2010 Distrib||0||3||0||0||3||3|
Table 2. Description of nets whichcame through the health post, including their owner, age, and number and sizeof holes.
Table 2 represents the net traffic atthe health post. The owner, net’s estimated age, and size and number of holesin each net were recorded. Holes were categorized into four groups: the widthof one index finger or smaller (Width index finger -), the width of two fingersor slightly larger (two fingers +), the size of a fist (Fist), and larger thanthe size of a fist—some holes/tears were as wide/long as 30-35 centimeters.Holes repaired at the health post by participants and staffers were reported inthe last column. Of the 21 serviced nets, holes in 17 were repaired throughoutthe day, totaling 136 holes sewn. When asked the age of nets, 14 of the netswere claimed to have been distributed to the population through the national distributioncampaign in 2010.
|Width Index Finger -||Two Fingers +||Fist||Fist +||Total Holes|
Table 3. Average number of holes pernet and average size of those holes.
As seen in Tables 2 and 3,respectively, 15 out of the 17 nets repaired were reportedly from the 2010distribution, and each had an average of 8.5 holes (6.6 smaller than a fist,and 2 the size of a fist or larger).
Table 1 shows that 30 people receivedinstruction on net washing, 15 of whom demonstrated this newly acquiredcompetency by washing their own nets and verbalizing the steps of correct netwashing. All 21 nets seen at the health post were washed and hung in the shadeto dry. Seven women (all 40+) and five boys (under 15) were trained totransform a square net into a round net; the seven women worked in groups todemonstrate this competency using a net, string, and wire.
|Women||Men||Girls (<15)||Boys (<15)||Total|
|Total Participants at HP||24||12||18||22||76|
|Population of Village||231||196||218||300||945|
|% Village directly impacted||10||6||8||7||8|
|Projected indirect impact||88||75||83||114||360|
|% Village indirectly impacted||9||8||9||12||38|
Table 4. Direct and indirect impactof project.
Table 4 presents the measured directimpact and assumed indirect impact of the project using village populationestimates from a government census in 2009. Seventy-six local residents weredirectly impacted by the intervention. This means, illustrated in Table 4, 8%of the village population was directly impacted. Assuming each adult representsan independent compound of 10 people, 360 residents, or 38% of the population,were indirectly impacted—this estimate does not account for the indirect impactfrom the youth present, word of mouth around the village, or those exposed tothe rice sacks or malaria prevention messages on the speakers. Though, malariaspeeches were audible throughout the village. Lastly, an unknown number ofpeople were exposed to the rice sack display; however, the road lined withsacks is heavily traversed.
Throughout the project, lack of space, insufficient number of personnel, recording the age of nets, and getting people to show up were identified challenges. The health post did not have enough shaded area for the sewing station and each station easily became crowded. Around lunch a woman going into labor came to the health post. The sewing station was set up immediately in front of the maternity clinic. Staffers quickly moved the station, further limiting the space available, and had to lower the volume of the speakers. The event was competing with the health post for space.
An insufficient number of personnel may have also contributed to bottlenecking of space. Over 20 nets had multiple holes, and some holes took a long time to repair. Monitoring hole-size and attendance at the health post also proved taxing. Additional personnel could expedite the net repair station and increase the monitoring capacity for subsequent evaluation.
Recording the age of nets also proved to be difficult. Most nets are believed to have come from a net distribution in 2010, but some appeared older. People often had trouble recalling when they acquired nets. Some knew, a few did not, and others assumed their family received the net during the last distribution. The tags on nets that can help track the production and distribution date were often ripped off or too faded to read. The variation in holes per net from the 2010 distribution, found in Table 2, from 0 to 18, may suggest differing rates of use, maintenance, or inaccurate reporting of net age. Holes per net may provide insight into the net’s age; however, further analysis is needed to establish the relationship.
Unfortunately, not as many people as expected came to the health post. The week leading up to the event Gascoigne was preoccupied filling and sewing shut rice sacks. Despite explaining the project to villagers in passing conversations, asking others to spread the word, using 196 rice sacks in the formation of lights on a runway as a visual display to attract passers-by, and using speakers at the health post loud enough to be heard across the village to invite people, some did not come because they did not receive a personal invitation and others because they were attending a funeral in another village.
First, it is important to choose a venue separated from the health structure to prevent interference with the normal operations of the health structure, all the while, ensuring the health structure staff is involved in the project. The venue should also have ample space for the net sewing station and accompanying chairs. Providing more room and resources for this station will help prevent a bottleneck.
Second, it is better to have too many personnel than not enough. The net sewing station and general ‘monitoring and evaluation’ required more support. At least two volunteers and one or two local youth assisted at the sewing station the entire day, and though only 21 nets came through the station, they were all usually busy assisting in sewing holes. For the 70 people who came through the health post, adding one person, a minimum of five people in total, devoted to the sewing station would have been sufficient. Another person devoted to monitoring general attendance at the health structure and the age, or stated age, of nets would have been useful.
Third, confirmation of net age remains elusive. Tracking tags were often torn or too faded to read. If the policy of labeling distributed nets with head of household name, location and date of distribution continues, the potential for net-age identification should increase.
Fourth, it is necessary to notify everyone in the community early. The attractiveness of 100 meters of colored rice sacks and speakers loud enough to be heard throughout the entire village were not enough. Everyone must be invited. For example, in Gascoigne’s village, he needed to emphasize that the project was not solely a Pulaar or Jalunke project, the two ethnic groups of his village. He hoped to announce the event on the mosque speaker, but was not able to—this may have been a good way to get out the word the previous day.
Since the project, I have had requests to come to homes to teach people how to sew holes in nets and to help them sew these holes. I also had a request to help a women make her square net round. These actions will be documented as a secondary impact of the intervention. A survey to be conducted between August and September 2012 will assess net usage, number of holes in nets, and knowledge of net repair and maintenance in compounds across his village. Cases of malaria treated and number of antenatal care visits attended at the health post will be monitored. This information, indexed for rainfall, will be compared to the same data collected in 2011.
This project has potential to be duplicated and scaled-up, though long-term monitoring and evaluation on a larger scale may not be practical. The impact of this intervention is multiplied as it coincides with the NetWorks routine distribution of nets; this project can educate the population about this new distribution system while emphasizing the importance of existing net maintenance. The constant availability of cheap nets, education of net use and maintenance, promotion of early treatment, and motivation to save rice establish a foundation for preventive health for malaria.
The meaning of the rice sack road was instantly obvious to the people of Fongolimbi. All that money the community was spending on treating severe malaria could be better spent on food.