What's in a Net?

In Senegal, I’m an anomaly.  For a country that lists malaria as one of its greatest threats, I’ve been largely unaffected.  My host family, my friends, my co-workers – I’m thankful to say that none of them succumbed to malaria during my time here, but even more strangely, none of them ever even contracted malaria.  My local health post, situated in a bustling urban neighborhood, documented only two treated cases of the disease during my first rainy season.  It seems that I live in a pocket where prevention - through both treated mosquito nets and insecticide sprays - has truly taken hold.

But outside of my immediate surroundings, malaria is brutal. Worldwide, experts estimate that the disease kills a little less than a million people each year.  230 million contract malaria every year, and even if they don’t succumb to its clutches, the experience is far from pleasant.  Among Peace Corps volunteers, we consider the possibility of malaria with questions such as: can you do anything more than lie on the floor and groan?  Do you feel like you’re dying?  Is this the worst pain you’ve ever experienced in your life? This disease keeps kids out of school for weeks, costs struggling countries billions of dollars, and makes the flu a walk in the park.

One area with a surprisingly high incidence of malaria is the district immediately next to mine, Pout.  Another Peace Corps volunteer, my friend Andrew, lives in Pout and was approached by his local health post to collaborate on a malaria education project. Pout is labeled a red zone – the highest and most dangerous classification – by the Senegalese Ministry of Health due to its high malaria infection rates.  The health post wanted to organize a tour of local middle and high schools, where we would present short presentations to reinforce knowledge about preventing malaria.  Middle and high school students, they explained, are ideal targets for behavior change activities, having the capacity to absorb information, practice it, and pass on the information to their families and neighbors.

And so that’s what we did.  Seldom do Peace Corps projects unfold so easily, but with the enthusiasm of the Pout Health Post in organizing logistics, the enthusiasm of each school in welcoming us, the assistance of a USAID Small Projects Assistance grant, and that dependable Peace Corps volunteer knack for creating educational content, we pulled off a successful project over the course of a week.  

A local ICP (head nurse) reinforces our points for students in Wolof.  I stand next to him, being extremely supportive.

At each school, we teamed up with local nurses, health volunteers, and teachers to lead a presentation about using bed nets to combat malaria.  We chose to focus on bed nets because not only are they the most cost-effective measure for reducing transmission, but a recent campaign by PNLP (National Program to Fight Malaria) had just distributed free impregnated mosquito nets to every household in the district.  In the end, we spoke to over 1900 students, teachers, and health workers at nine different schools.  Success!

But because we had a lot of time driving in cars between schools, I started thinking about behavior change.  Behavior change is a Peace Corps catch phrase and the end goal of most education projects: the idea of giving people knowledge that they translate into action.  It’s more than simply explaining the benefits of washing your hands, keeping business records, or rotating field crops; successful behavior change makes those actions the reflexive norm. For malaria, everyone (NGOs, international organizations, Senegal, Peace Corps, and every actor in between) wants to make sleeping under a mosquito net that undisputed, reflexive norm, with the obvious benefit being a reduction in malaria.

In many of the schools we visited, the students demonstrated impeccable knowledge about malaria transmission and prevention.  Public-service announcements and propaganda about bed net usage permeate Senegal, through billboards, radio, television, and school lessons, so this was no surprise.  What caught my attention was an impromptu survey we took at the beginning of each program: only 52% of the students said they had a mosquito net in their room, despite the recent universal coverage campaign.  Their behavior didn't measure up.

More strikingly, only 22% of the 1900 students had slept under their mosquito net the previous night.  Millions of dollars have been poured into campaigns about using impregnated bed nets.  Senegalese celebrities have joined the cause, grand events are hosted, and free nets are distributed by health workers with the intention of covering every single bed.  And yet – only 22% of the students, undoubtedly one of the most educated groups, were using the nets.

Wait, seriously?  None of you slept under your bed nets last night?  Did I stutter with my question?

Behavior change is hard.  And I don’t completely blame the students for avoiding  their mosquito nets.  In many ways, malaria is a fact of life here, and many people are willing to take their chances with it.  Plus, nets are hot.  Nights in Senegal leave people sweating on mattresses, desperately waiting for the smallest twinges of a breeze to give them a few seconds of relief.  Who wants to compound that heat by wrapping themselves in a gauzy net every night?  Personally, I use my net religiously, but mostly because I’m terrified of cockroaches, mice, lizards, and rats the size of terriers, not because I know malaria might kill me.

Truthfully, our malaria tour reminded me of all the knowledge Americans push aside with regularity – smoking, drunk driving, using condoms.  Simply knowing something is dangerous isn’t really enough to move people to action, or moreover, prevention.  So what does guarantee compliance, 100% of the time?  What changes behaviors?

Obviously, I don’t have the answer.  During our program, we inadvertently employed a host of different approaches.  We tried to imbibe the students with a sense of responsibility and ownership, telling them that they were responsible for being agents and passing on the information to other people.  We outlined the costs of having malaria – financially, lost school time, health-wise – and cut them against the cost of prevention – using a free, impregnated net.  We tried to inspire them with attainable goals of eradicating malaria.  We tried to make them see their nets not only as a protection for themselves, but a weapon to actively kill mosquitos that could harm other people in their homes.  The Senegalese health workers even tried to shame students who admitted to not sleeping under nets, making them stand up and address the class.

Behavior change technique: throw some children under a net, pretend to attack them with a life-size homemade mosquito, and do some sassy finger wagging.  Success rate for this method TBD.

In the end, I think our program succeeded in giving students information beyond the catchphrases and slogans they’ve memorized from public health campaigns.  I think the students appreciated the novelty of discussing malaria with some crazy strangers and charismatic health workers, and a few of them were able to get free nets that day. 

I have no idea if 22% or 0% or 100% of our students slept under their mosquito nets the night after our visit.  Ultimately, I hope that whatever they did, they did it with a better understanding of whatever consequences they were choosing.  I hope they realize just what's in a net: the capacity to cut down malaria, to ensure school and work attendance, the chance to wipe out malaria-infected mosquitos, the chance to save lives.  A net has a pretty high net worth.  Hopefully, knowing what's in a net can start translating into who should be in a net -  and less needless malaria by this time next year.  

Part of our Pout Malaria Tournee team with a lot of random people who happened to be passing by when the photo was taken.  Teamwork!

You can read a case study about our project here: http://www.pcsenegal.org/case_studies/146-pout-malaria-tournee