ITNs are distributed across sub-Saharan Africa in mass distribution campaigns to ensure that as many at risk people as possible use them and are protected from malaria. But how long do they last and what affects their longevity? PMI VectorWorks has undertaken three-year durability monitoring activities in eight different countries to answer these questions. Throughout the process, the project has strengthened capacity for in-country researchers to take on the activities and answer these questions themselves.
Durability monitoring for ITNs includes assessing the physical and insecticidal integrity of nets using standard guidelines, which VectorWorks developed with PMI. During durability monitoring, a representative sample of nets —distributed to households during a mass campaign—is identified within six months after the campaign and then followed up after one, two, and three years post-distribution. For each round of data collection, at each sampled household, the field teams interview participants using a questionnaire and direct observations, counting holes and assessing the physical durability of each of the family’s ITNs. The field teams also take some ITNs back to the laboratory to assess whether the nets still have enough of the insecticide to kill mosquitoes. These households get a replacement ITN in return.
Durability monitoring is conducted because we want to know how long nets last – is it 2 years, or 5 years? What about the physical integrity – are there holes or burns? Does cooking or having kids or spreading on a fence to dry after washing them change the lifespan? What about climate, and urban versus rural use?” Durability monitoring is essential to inform national strategy decisions regarding how often to replace nets, and how to promote appropriate net care to maximize the life of the nets. Net durability varies significantly by location, even within the same country, and local data provide a crucial piece of the puzzle that will help national malaria programs optimize ITN distribution frequency and population protection. Furthermore, building capacity of local teams is instrumental in building country capacity and ownership of the durability monitoring process.
Capacity Transfer Methodology for Durability Monitoring
The approach to building capacity in ITN durability monitoring varies slightly from country to country, depending on the context and existing capacity, but largely involves the following:
In countries where durability monitoring is underway, the capacity transfer process is already showing to a crucial element in achieving country ownership of the process. Dr. Albert Kilian of Tropical Health notes: “I believe that the capacity building we do in DM is very good. As we move to the 12 and 24 months data collections I can see during the trainings that people are proud that they are making progress in better understanding the concept, interpreting the data, or being told that the data they collect is of excellent quality.”
Capacity Transfer Case Studies
Zanzibar is one of the best examples of durability monitoring capacity transfer. From the outset, the Zanzibar Malaria Elimination Program (ZAMEP) staff played a significant leadership role in the activity: the ZAMEP ITN Manager is the activity focal point, working with Zanzibar Medical Research and Ethics Committee (ZAMREC) on ethical clearance and overseeing communication with relevant government and local authorities. ZAMEP conducted engagement meetings with local leaders from each site, and ZAMEP site coordinators supervised data collection and uploaded data nightly for review, feedback, and analysis.
A key factor in the successful capacity transfer in Zanzibar is that ZAMEP staff are government employees, which has resulted in near 100% retention of data collectors throughout the process, as well as familiarity and acceptance by the communities they are working in. “People have great trust in government officers, especially those from the Ministry of Health,” noted Kanuth Dimoso, the study manager overseeing durability monitoring as PMI VectorWorks Tanzania’s M&E Officer. Their high level of retention has been key in the successful rollout: “They know where they went last time, who they met, and what they found out. This consistency means they don’t need to spend time re-locating areas visited last time.” Additionally, refresher trainings were shorter, saving time otherwise spent on training new data collection teams.
Democratic Republic of the Congo (DRC)
In DRC, local capacity to conduct durability monitoring was essential from the get-go, due to restrictions on travel to and within DRC for project staff. The initial training and data collection were conducted in 2016 in partnership with the Kinshasa School of Public Health (KSPH) and the National Malaria Control Program (NMCP). However, in subsequent rounds of data collection, the local team assumed leadership for the training and data collection. KSPH and NMCP were able to organize and lead the training of the teams in the field and the collection of data. “The [initial] training received in 2016 was very important and interesting as it was our very first experience in assessing sustainability following the PMI protocol,” local co-investigator Dr. Paul Mansiangi noted. That capacity transfer proved to be instrumental in ensuring the subsequent rounds of training and data collection could be done independently, with virtual assistance rather than in-person assistance from the PMI VectorWorks team. Since nightly data uploads and feedback were impossible in the very remote sites, the KSPH team reviewed the data themselves, fixing errors and troubleshooting with team members, and uploading data once back in the capitol.
After three rounds of durability monitoring, KSPH and NMCP are currently able to conduct all stages of the assessment using the PMI procedure, from the protocol design, through the organization of data collection and analysis, to drafting the report, disseminating results to national stakeholders. Dr. Mansiangi noted: “After the baseline and month 12 assessments, the analyses were done by Dr. Kilian. After the 24-month data collection, we performed the analyses alone and Dr. Kilian also did the analyses on his side. Then we compared the results obtained by both teams to see if we needed to correct anything. For the last phase, we are supposed to do the analyses ourselves. This is what we intend to do to strengthen independent monitoring of LLIN durability.” This example of increased leadership and independence over time exemplifies what capacity transfer should look like.
Having completed baseline fieldwork in April 2018, Kenya is in the beginning stages of transferring capacity to conduct durability monitoring. Nabie Bayoh of the Pan African Mosquito Control Association (PAMCA), previously the local coordinator, noted that the baseline was successful for a few reasons. Mr. Bayoh noted that it was essential to choose the right cadre to do data collection, and for Kenya, those data collectors were drawn from PAMCA and Kenya and the Adaptive Management Research Consultants in Kenya (AMREC). PAMCA and AMREC have members across the country, including Ministry of Health and public and private research and learning institution employees, many of whom were already versed in durability monitoring through previous PMI studies. Mr. Bayoh noted it was important to have data collectors with a higher skill level in order to conduct interviews and net assessments with tablets, and membership in PAMCA or AMREC to ensure their accountability during the process. Data collectors were aided in their data collection efforts by community health volunteers (CHVs), who may not be as well versed with using tablets and collecting data, but are essential for community entry. “CHVs are good at knowing where houses are. Then people trained for data (data collectors) proceed with consenting and interview.” This partnership between data collectors and CHVs has thus far proved to be instrumental in smooth roll out the data collection.
The data collection method of using tablets has been an effective way of ensuring accuracy in data collection. Mr. Bayoh noted that “Data was being uploaded every day. Somebody on the other end can immediately check data and send feedback to the field the same day. [He/she] can ask the team what went wrong, or assign them to go back to the household to clarify.” Since data is corrected right then and there, this adds a capacity building element to ensuring data is collected and uploaded correctly. If there is an issue, data collectors can go back to the household and re-collect or correct data before going on to the next household. With Kenya heading into the next round of data collection in November 2018, there are still lessons to be learned from their efforts to build local capacity.
Capacity transfer is still in progress in the other countries where durability monitoring is still starting up. However, in Zanzibar, DRC and Kenya, some key results of capacity building are already clear: local researchers are conducting durability monitoring independently; data driven decision making is being led locally; and there has been a demonstrated increase in local capacity to use new electronic data collection tools.
This process of capacity transfer aligns well with USAID’s Journey to Self-Reliance which emphasizes the importance of building capacity of countries to solve their own development challenges. The intention is that the increased capacity realized through durability monitoring will enable and empower local teams to be able to:
- Identify household and behavioral risk factors for ITN durability, and target social and behavior change interventions accordingly
- Supply sub-regional data on ITN median lifespan that could reshape ITN distribution strategies to optimize ITN coverage levels
Jennifer Boyle is a Senior Program Officer at Johns Hopkins Center for Communication Programs.