In Tanzania, despite recent declines, malaria continues to contribute significantly to morbidity and mortality. The…
By: Jennifer Boyle and Sara Berthe
“Everyone did their job to ensure success for the entire district,” Ousmane Yattara reflected proudly on the National Malaria Program’s recent distribution of insecticide-treated mosquito nets (ITNs) to school children in Boffa district in Guinea. Named by the District Education Office (DPE) Director as the focal point to this activity, Yattara was integrally involved in the regular planning meetings, ensuring that local leaders, community health agents, parent teacher association members, and teachers actively participated in planning and implementation to ensure net distribution went smoothly. By the end of the distribution, teachers in Boffa district had successfully distributed 21,617 ITNs to school children in 182 schools, resulting in 100% coverage of eligible students. “The team worked seriously with rigor and promptness,” Yattara noted. The school distribution was supported by VectorWorks, a five-year global project, funded by the U.S. President’s Malaria Initiative (PMI), that aims to scale up vector control for malaria prevention through improved distribution of ITNs, optimal rollout of promising alternative vector control tools, and global policies that are informed by the use of monitoring and evaluation data.
The case for school-based distribution
In 2016, Guinea conducted a national universal coverage campaign, aiming to distribute 1 ITN for every 2 people across the country, and has another planned for 2019. ITNs are also routinely distributed in Guinea when pregnant women attend prenatal visits and when children receive their measles vaccination. However, because ITN access declines between campaigns due to wear and tear on the nets, PMI and the National Malaria Control Programme (NMCP) sought an interim measure to boost coverage. PMI and NMCP wanted to find an additional channel to distribute ITNs that would help fill gaps in ITN access between campaigns.
In January 2017, VectorWorks conducted a continuous distribution assessment to determine an effective channel to respond to the NMCP’s need. The assessment found that, based on the strong ties forged between the health and education sectors during the Ebola outbreak, especially the strong delivery and communication systems, school-based distribution would be a feasible channel. The assessment recommended that schools distribute ITNs to students in grades 1, 3, and 5 of primary school, to bolster ITN coverage without oversupplying households. In this way, as students progress through primary school, they receive an ITN every other year. Based on these findings, the NMCP and VectorWorks began planning a school distribution pilot to evaluate the impact of this approach on overall ITN coverage.
Careful planning ensured community involvement was integrated into the distribution activity right from the start. With support from VectorWorks, the NMCP took the lead in national-level coordination of the activity. VectorWorks organized district-level coordination meetings to bring together the education and health teams, who identified teachers, community health agents, and parent-teacher association members associated with each school for the on-the-ground planning and distribution. It was this planning, led by the local coordination committee, which ensured local buy-in and timely completion of activities.
The district coordination committee was instrumental in determining the best way to get the word out about the school distribution. The committee determined which messages were appropriate for the local context, and, translated into local language, these messages appeared on radio programs, on job aids for parent-teacher association members and community health workers, as well as on posters for school classrooms. These messages were also delivered by the students themselves, and the committee chose simple messages that were easy for students to remember and relay home, such as: “Only a mosquito bite causes malaria,“ “An ITN is the most efficient protection against malaria,” and “The whole family should sleep under a mosquito net every night.” Communication began more than a month before the school distribution, to give everyone ample time to hear the messages. Consistent messaging from many sources helped to both reinforce the positive messages around correct and consistent net use and dispel rumors about how malaria is transmitted.
The district committee actively involved members of the Islamic League and local Christian leaders in dissemination of key messages the religious leaders, members of the PTA, and community health agents ensured wide dissemination of key messages about ITN distribution, including dates and times, how best to use an ITN, an explanation of the pilot, and which classes would receive nets. An interactive radio program and roundtable discussion gave information about the activity and enabled community members to call in and ask questions. Most callers wanted to know why only students in classes 1, 3 and 5 were receiving nets, and when others would receive them. People also called to comment on the shape of nets, preferring conical shaped nets to rectangular ones. The ability to ask questions allowed community members to dialogue about the distribution and be more than just receivers of messages.
Partnerships + Community Engagement = Success
The pilot activity was deemed a success by the district. Yattara noted that two days after the distribution, during a routine education-focused supervision activity, that he saw many ITNs hung in the shade, airing out before they were hung inside for sleeping. Yattara declared: “Seeing this reassured us and I was proud and happy to see them. I knew they were from our distribution and that showed me that the project was a success.”
Several key components ultimately led to the success of this campaign:
- Support from all levels was critical. Although much of the planning took place at district level, there was early buy in and support at national level which continued through the distribution. Representatives from PMI, the NMCP, VectorWorks, the Ministry of Education, as well as various local officials including the Regional Health Director and local administrative heads lent their support and attended the launch of the activity.
- Coordination between health and education ensured wide-spread buy-in for the distribution activity. Typically, distribution has been done through the health sector alone. This pilot built on the relationship between health and education sectors strengthened during Ebola, and used that to gain support and involvement of school administrators, teachers, parent teacher associations and students alike.
- Community involvement was critical during the campaign. Messaging from different types of community leaders was key in building broad community support. Teachers learned about and were able to teach students about malaria prevention. Family and community members heard messages in the days leading up to the campaign, often from the students themselves, and came to schools with their students to receive the ITNs.
VectorWorks is conducting a household survey to measure the impact of the distribution on ITN access and use; the results will help the NMCP determine whether and how to scale up this pilot.
Jennifer Boyle is a Senior Program Officer at Johns Hopkins Center for Communication Programs. Sara Berthe is a Senior Program Officer on the VectorWorks Project at Johns Hopkins Center for Communication Programs.
The national level coordination team was led by the NMCP and VectorWorks, working in tandem with representatives from PMI, the Ministry of Education and health education offices as well as other malaria intervention implementing partners.