INTERNATIONAL CONFERENCE ON BEDNETS
& OTHER INSECTICIDE TREATED MATERIALS
October 29-31st
Background paper on the appropriate use of insecticide treated nets and curtains to accompany the presentation on Oct 29th.
By Valerie Curtis,Jean-Bosco Ouédraogo, Jo Lines,
"Give Us What We Want"
"Yes, do sit down. Sorry about the mud, it's hard to keep the place clean when it rains. At least it's not so hot now. Yes, I did hear something on the radio about some 'medicine' to put on bednets. They said it was supposed to stop the children getting ill. Yes, it does sound like a good idea. But there's not much you can do about the fevers. My little one had a fever last week. It's the damp that causes it. They always get sick around now. Do we have a bednet? Yes, the children's father sleeps under one sometimes, when it's not too hot. He likes it because the insects don't disturb him. Us? We use a coil when we have the money, if not we burn some tomato leaves or orange peel. The coils get rid of the mosquitoes, but they give me a headache and they make the children cough.""What do I think of buying a bednet for the kids? You must be joking! I have to buy them a bed first! I know someone who got the stuff put on her nets. She really liked it, everybody slept well, but it stopped working after she washed them. They told her not to wash them, but you can't leave a net more than a few weeks without washing it. Why not? I can tell you're not from round here! The kids wipe their hands on them, the smoke from the lamp makes them black. Only a real sloven would leave a net several months without washing it."
These are some of the things that mothers in Burkina Faso and in Tanzania told us when we asked them what they thought of insecticide impregnated mosquito nets. What they said raised fundamental questions in our minds about the IBN programmes we had hoped to set up. And we didn't have any answers to these questions. What do we do when children sleep on mats on the floor? What do we do if people don't think it is worth spending money on nets and insecticide? What sort of impregnation service should we offer if nets are going to be washed every two weeks? And how do we go about convincing people to use the nets, when they don't really believe that the fevers that they suffer from, have anything to do with mosquito bites?
The aim of this conference is to help us to develop insecticide impregnation strategies for the real world. We have gone beyond the days of the controlled trials of IBN efficacy, where we could get most of the inhabitants of a village to use impregnated nets by just giving them out. We are looking for sustainable solutions. This means that target populations will have to make the effort to procure nets, curtains, dipping and re-dipping for themselves. Whatever the type of IBN programme we are planning (health service based, NGO supported, commercial venture, etc), people are going to have to go to a lot of trouble to get and maintain IBNs. Buying or getting nets and curtains, maintaining them, washing them, getting them dipped and re-dipped requires not only time and money, but also a lot of determination. This paper argues that if we can't offer something that people can use easily and effectively, that is available, affordable and attractive, then we will fail. In other words, instead of trying to bend people's behaviours to fit our technologies, we have to bend our technologies to fit their behaviour.
Treat your net, or else..!
Faced with difficult questions like the ones mothers in Tanzania and Burkina Faso set us, we only had two options. One was to close our eyes to these problems and to continue with our plan to set up impregnation services and to try to convince everybody in town that their children would get sick or die if they didn't all buy nets and impregnate them regularly. The second option was to try to get some answers to those questions, in the hope that we could come up with something to offer people that met their needs, that they could afford, and that they would find attractive enough to want to go about getting and using.
It seemed to us that we didn't really have any option. We had to address the questions posed by our target populations from the start. But is this practical? Can IBN programmes find answers to such questions? And can they use the answers that they get to design programmes that will make people determined to go out and get the technology of IBNs? This paper suggests that it is indeed possible to get answers to key questions about the usage of IBNs. And we suggest that putting users at the heart of our programme; designing programmes around what they do, need and want, is the only way that we are going to get IBN technology widely adopted.
Finding out about users
So the first step in setting up out IBN programmes must be to find out about our users. This laying of the ground work is often called 'formative research' (Lefebre et al). We need to decide what we need to know about, formulate our questions clearly, and then decide how best to get the answers. Some of the questions we might want to ask are:
What is the best insecticide to use?
What is the best dosage?
Who uses nets? Are curtains a better option?
Should we provide a central dipping service, dip at home or sell dip-it-yourself kits?
Which members of the household take the decision to acquire IBNs?
What are the characteristics of our clients?
What is going to make people want to acquire IBNs?
What promotional strategies should we use?
How do people usually find out about new ideas?
How can we tap into existing channels of communication?
Once we have formulated a short list of key questions, the next step is to think up ways of getting them answered. This can often be quite simple. For example, a team in Dar-es-Salaam wanted to know which insecticide and what dose would be best for users. So they gave out nets with different insecticides and doses to groups of families and met with them once a month to find out what they thought. To their surprise they found that the nets had all been washed after eight weeks, despite all the injunctions not to. Mothers explained that they'd washed the nets in secret because they were so ashamed of the state of their nets. One said:
"since we are using kerosene lamps in just one to two weeks our nets need washing, even visitors will be surprised if you can wash all your other clothing while your net is black".
Another said:
"They need washing, they are very dirty, you can get colds by breathing through it."
So what did the team do? They certainly didn't go back to the mothers and try to convince them not to wash the nets for six months. Instead, they started looking for the right dosage of insecticide to reapply after each monthly wash (Miller et al.).
Formative research: dear questions, simple methods
In Bobo-Dioulasso, Burkina Faso, we wanted to set up a commercial treatment service, and this required finding out certain things before setting to work on a full-scale programme. Our first step was to work out a short list of questions, then we chose simple, practical methods that could give us the answers. Some questions, such as the current usage of nets and curtains, could be tackled using a household survey, others required more in-depth discussion in focus groups, or with clients of the dipping service. For some questions, the only possibility was trial and error. Key to developing the plan was to involve residents who knew the town well, who could judge which techniques were likely to produce useful results and which not. The table shows the work plan that we used.
Some of our questions were relatively simple to answer: for example, the household survey showed that only 20% of people slept under nets, but that 8 1 % of households had curtains. In focus groups women said that curtains were essential, otherwise "the house would look like a kitchen". We were told that nets have been falling out of use because of the rising costs. As a result, we decided to focus the programme primarily on dipping curtains rather than nets.
Slightly more difficult to answer, was the question of who our clients were. We asked participants in five focus groups (two with men and three with women) to tell us about who makes decisions about spending on household items and who goes out and buys insect sprays and coils. We learned that the male head of household generally decides about buying a net and finds the money for insect sprays and coils, but usually his wife would ask him to do it. Interviews with clients of the existing service confirmed that the men had usually made the decision to impregnate nets and curtains. (Ouédraogo et al). So we took male breadwinners as our main target group and women as our secondary target group.
Table. Formative research plan for the Bobo-Dioulasso insecticide impregnation service
| Objective | Questions | Research Methods |
| Potential clients | Who is the purchaser? What are the characteristics of clients? | Representative household
survey Focus group discussions |
| Product | Curtains or nets? Which insecticide? What dosage? What frequency of dipping? In what format is the product offered? | Review experience elsewhere Pilot dipping service Bioassay Trial and error Client Interviews |
| Positioning | What will motivate the seeking of dipping and redipping? | Client interviews Focus group discussions |
| Place | Where to offer dipping? | Pilot central, satellite, domestic services |
| Price | What do people spend on
mosquito control? What price will allow a reasonable return? | Client interviews Pilot dipping service |
| Promotional strategy | What channels of
communication? What Logo/slogan? What packaging? What promotional materials and events? | Client interviews Focus group discussions Intercept interviews Trial and error |
The object of desire
Perhaps the hardest question to answer was the most basic one. What would convince people to get up, go out, use their valuable time, spend their hard-earned money, to get IBNs for themselves? The success of our programme depended on getting a good answer to this question. Again, the secret lay not with us, but in knowing the wants, needs and habits of the users.
In Bobo we asked 20 clients of the existing dipping service why they had got their nets and curtains dipped. Typical responses were:
"It gets rid of mosquitoes in the room"
"It gives you peace from the mosquitoes"
Not one of the clients said that they had used the dipping service to prevent malaria.
Of course, no one likes being bitten by mosquitoes. All populations in Sub-Saharan Africa go to great lengths to avoid being bitten. In Dar-es-Salaam, Evans et al. asked people what they did about controlling mosquitoes at home. To their surprise, they were able to calculate that over a million dollars a month was being spent in the town on commercially bought coils, sprays and bednets. This expenditure was to combat the mosquito nuisance and had little, or nothing, to do with preventing malaria. The household survey in Bobo suggested that households were spending about $9.00 a month on mosquito control on average (amounting to half a million dollars a month in total).
Findings such as these suggest that people want IBNs much more to counter the nuisance of mosquitoes than as a health technology. In Bobo-Dioulasso we have decided to drop the health argument entirely, and to concentrate on promoting impregnation to give the family peace from mosquitoes. Our reasons are the following:
We don't think it is possible to explain about the relationship between Anopheles gambiae and malaria simply and convincingly to a large population. (Not to mention explaining about the different role of Culex)
Children will still get fevers, even if they sleep under nets, so the health argument will not be convincing
Negative messages trying to inspire fear of sickness are generally very poor motivators of behaviour change (Curtis)
People are already spending a lot on mosquito control
Preventing mosquito nuisance is a simple, easy to understand and convincing message.
One result of adopting this strategy is that we have had to modify our product. If treatment of curtains and nets is being promoted to reduce mosquito nuisance then we need to find an insecticide and dosage which can produce an obvious impact on the mosquito nuisance. In a process of trial, error, client interviews and bioassays, we finally adopted deltamethrine on curtains at one and a half times the normal net dose (40mg/m'). This proved satisfactory at repulsing and killing Culex, which are the main nuisance biters in this urban setting.
Of course, our aim is still to prevent malaria. And nobody would deny that health education is a useful thing to do. Villagers who understand about malaria transmission are best placed to find solutions to the problem for their own localities and are key members of any product development team. Though many of our target users have heard that mosquitoes cause malaria, if you ask what caused the child's most recent bout of fevers, users explain that it is due to climate or wrong foods, like the woman in the example at the beginning of this paper. In the Bobo-Dioulasso region, for example, serious forms of malaria Soumaya-ba are thought to be due to sorcery or to curses from jealous enemies (Gbary).
It is hard to see why people should want to change their long-held beliefs, just because they hear something else from the western biomedical belief system. So we are probably fooling ourselves on two counts if we rely on health education to motivate IBN seeking. Firstly, it is vain to think that we can get huge numbers of people to believe that mosquitoes are the main cause of malaria over a short time span. Secondly, even if we did have the resources and the credibility to convince everybody that this was so, it is unlikely that this knowledge, on it's own, would be enough to motivate people to seek out IBN technology.
In the excellent 'Marketing for Dummies' (IDG 1997) Hiam suggests that one should never try to sell a product that can't be explained in five words (or an absolute maximum of twelve words). IBNs against mosquitoes is a simple and convincing message. IBNs against malaria probably isn't.
Having decided that mosquito nuisance was our primary argument for getting curtains dipped and re-dipped, we could then move on to developing a promotional strategy. Again, this grew out of our formative research. We asked about the channels of communication that our target audiences used and found out, for example, that we could reach about 67% of male household heads with a regular radio spot just after the evening news in a local language. We used what we found out to develop a variety of promotional media, all using the same simple message, which we tested and re-tested in focus groups with potential clients.
Some questions remain to be answered. For example, we have not yet been able to assess whether home-dipping kits would be more acceptable than a central dipping service, but we will try this out as soon as kits become available.
Formative research: quick and cheap?
We saw then, in Bobo-Dioulasso, that it was possible to get useful answers to our questions relatively quickly and cheaply. The field work carried out by a multi-disciplinary team took only about two months, though the piloting and trial of promotional strategies took longer. We have not, though, abandoned our research activities now that we have designed the programme: on-going monitoring and evaluation will help us to continue to adapt to our clientele.
Of course, not all programmes will have to do so much formative research themselves. Conferences like this allow us to find some of the answers that we need in the experiences of other programmes. But it will always be necessary to found programmes on an understanding of local users, their habits, needs and wants. The key to doing this successfully is to formulate the key questions clearly and to make a commitment to finding out what people really do and think.
Turning programmes inside out
However good we are at listening to our users, at adapting what we offer to their needs, and at finding strategies for convincing them to acquire IBNs we still can't expect overnight success. It is bound to take a long time before a strange new innovation like chemicals on a bednet or on curtains becomes widely understood. It will take even longer for people to see and be convinced of the advantages. And then it will take a great deal longer before significant proportions of the population become dedicated dippers and re-dippers. So widespread, sustainable IBN usage is a long-term goal, which is probably not achievable in just a few years. It would be highly unhelpful to public health if, in our enthusiasm for IBNs we lost sight of other measures, such as prompt and correct treatment, which are still going to be vital for many years.
If IBNs are to "take off" and be adopted on a large scale by populations at risk of malaria in the 21" Century then we have a lot of work to do. In this paper we have argued that the only way to succeed is to put people like the women at the beginning of this paper first. We need to put what they want, need and do, at the heart of our activities. This requires turning our programmes inside out. Instead of trying to solve our problem (reduce malaria prevalence) we have to find ways to solve the users' problems. Instead of using our medical logic, we have to find out about the logic of ordinary people's lives. Instead of trying to force a new idea on people, we have to understand how to offer them something that they are going to want so much, that they will be prepared to go out and get it.
References
Curtis V, Kanki B, Gbary R and Sinha P. Hygiene education or hygiene promotion? Time for a rethink. Submitted to Tropical Medicine and International Health
Evans PJ, Lines JD, Ismail F. Sustainable urban malaria control for sale? Existing household behaviour and the future use of impregnated bed nets in Tanzania. In preparation.
Gbary R- Les d6terminants de l'utilisation de la chimioprophylaxie du paludisme chez la femme enceinte au Burkina Faso. Universit6 de Montr6al.These de Doctorat. 1995.
Hiam A. Marketing for Dummies. IDG Books Worldwide Inc. 1997.
Lefebre C. Social marketing. In Health Promotion: disciplines and diversity (Eds: Bunton & Macdonald) Routledge, London 1992.
Miller J, Jones C, Ndunguru S, Curtis V, Lines J. A new strategy for treating nets. Part 2. The effects of net users perceptions and practice on insecticide dosage. (Submitted to Tropical Medicine and International Health.)
Ouédraogo J-B, Curtis V, Diabate A, Kanki B, Coulibaly SO, Boner A, Leake ES. 'The enemy of the mosquito': formative research defines a new social product. In preparation.
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