Yukyan Lam
Delta Omega Scholarship - Abstract
Project Title: Outdoor Sleeping and Other Risk Factors for Malaria Infection in Northern Ghana
Advisor: Professor Steve Harvey (Social and Behavioral Interventions, Dept. of International Health)
I.
Introduction and Research Aims
Malaria is the leading cause of morbidity in Ghana, and the number one cause of mortality in
children under five.1,2 Since 2008, the National Malaria Control Program has intensified efforts to prevent
malaria by increasing coverage of insecticide-treated bed nets (ITNs) and indoor residual spraying (IRS).
From 2008 to 2012, over 4.8 million LLINs were distributed and 950,000 residents received IRS
nationwide with support from the President’s Malaria Initiative (PMI).3 In the largely rural Northern
Region, net ownership increased from 27% (in 2008) to 82%, and net use among children under five rose
from 11% to 52%.3 Yet despite encouraging levels of ownership and use,1 parasitemia levels in the
northern savannah have not decreased as expected, remaining around 50 percent in children under five.2
PMI now points to “evidence indicating that…IRS activity in the Northern Region is not having the
intended effect on parasite prevalence and malaria morbidity is building.”2 This is disconcerting, as severe
malaria may hinder long-term development even when a child survives.4 Parasitemia is also associated
with anemia, low birth weight and other adverse pregnancy outcomes.5
In explaining the persisting high levels of parasitemia, a salient gap lies in our lack of knowledge
regarding nighttime behaviors and sleeping patterns of Northern Region communities. Survey data
generate only a yes/no answer to the question of whether the respondent has “slept under a bed net”
during the night prior to the survey.1 This ignores various complexities, which may explain the observed
trends. There is lack of information on whether bed nets are being properly secured. The extent to which
people enter and exit the net throughout the night and whether they re-secure the net each time is also
unknown. Moreover, preliminary and anecdotal evidence suggests that people may often sleep outside
without a net first before moving indoors, likely limiting the effectiveness of IRS and LLINs, as outdoor
biting is common in the north.6 More studies are needed to assess when and why people sleep outside
without a net and the characteristics of bed net use more generally.
The proposed project seeks to employ and promote the method of direct nighttime observation to
identify sleeping patterns, characteristics of bed net use, and other nighttime behaviors that may be
reducing the effectiveness of bed nets and IRS in the Northern Region. This principal approach will be
complemented by in-depth interviews, focus group discussions and the participatory creation of seasonal
calendars and risk diaries. Results from our research will be used to formulate behavior change
interventions to reduce behaviors that increase malaria risk and to make recommendations for future
malaria control efforts. Specifically, the objectives will be to:
1. Understand the factors that motivate outdoor sleeping (e.g., hot weather, poor indoor ventilation, lack
of electricity to power fans, perceptions of malaria risk).
2. Map outdoor sleeping patterns in purposively selected areas, considering potential variation based on
community type (rural village, town or urban setting), geography and sociocultural characteristics.
3. Assess specific characteristics of bed net use and occurrence of bed net entry and exit in households.
4. Identify other nocturnal activities such as outdoor social, cultural and occupational events that occur
during mosquito biting hours.
5. Formulate recommendations for future malaria control programs, and develop potential interventions
to reduce behaviors that contribute to malaria risk.
II.
Methods
The principal data collection method we will use is direct nighttime observation, whereby observers
observe purposively sampled households from late afternoon until the following morning, and note
activities—along with corresponding times—undertaken by household members. Observers will use both
a structured checklist and free-hand notes to document behaviors that might increase exposure to malaria
Yukyan Lam
Delta Omega Scholarship - Abstract
vectors. For example, observers will document when inhabitants go to bed, all instances of bed net entry
and exit, outdoor sleeping activity and other nocturnal activities. They will note characteristics of
household members and features of bed net use (number and types of bed nets used, the manner of
securing the bed net, and who sleeps in each bed net).
Households will be selected as follows: 10 households from rural villages with no electricity, 10
households from rural villages with electricity, 10 households from rural towns, and 10 households from
the urban area of Tamale. We will identify households maximizing ecological variation and thus type of
mosquito habitat within each community. Recruitment will include households representing a range of
economic activities. Presence of pregnant women and children will serve as additional sampling criteria.
With the aim of achieving methodological triangulation, we will also supplement the direct
nighttime observations with in-depth interviewing, focus group discussions, and community-created risk
diaries and seasonal calendars. We aim to interview 10-15 community health workers and officials of
villages targeted by bed net and IRS campaigns. We propose conducting 3-4 focus groups to cover the
three different community types (rural village, rural town and urban), with 8-10 participants in each
group. Topics to be addressed in the interviews and focus groups include outdoor sleeping and the reasons
behind it, nocturnal social and occupational activities, perceptions of malaria risk, and perceived efficacy
of bed net and IRS interventions. Finally, we will also work with community health workers to initiate the
creation of risk diaries and seasonal calendars. Regarding the risk diaries, literate volunteers in each
participating community will be trained to keep diaries noting situations where they observe residents
engaging in risky behaviors. They will also summarize conversations related to these activities between
members of the community. Health workers will also create seasonal calendars to reflect variations in
precipitation, humidity, temperature, vector activity, and sleeping pattern based on seasonality.
Regarding data analysis, analytic triangulation—using different processes and templates for
analyses—will be fundamental. From the direct observations, we will create ‘time-tracking charts’ for
each household, listing nighttime activities and their corresponding times. We will compare these charts
with entomological data on malaria vectors, superimposing nighttime activities with known mosquito
biting hours. We will also derive summary measures reflecting characteristics of bed net usage and the
extent of bed net entry and exit. Direct observation data will additionally be used to produce maps of
outdoor sleeping patterns, thereby elucidating the types of households, communities and geographic
contexts in which it is more likely to occur. Analyzing and coding the observation reports, interview
transcripts, and focus group transcripts for the activities of interest, we will assess and compare trends in
behaviors occurring across communities of different characteristics.
III.
Significance
Direct nighttime observation has unique and relatively untapped potential for capturing hard-todocument behaviors in their natural setting. A better understanding of sleeping patterns and other
nighttime behaviors can contribute to explaining why ITNs and IRS appear more effective in some
settings and not others, and why malaria control campaigns do not always produce the differences
expected between intervention and non-intervention groups. This understanding can be used to formulate
behavior change interventions that can complement the deployment of tools like bed nets and IRS, and
render them more effective. By demonstrating the utility of direct nighttime observation in northern
Ghana, we hope to make a case for the method’s application in other places that are also struggling to
enhance the impact of IRS and ITN. Moreover, as research on the adaptability of malaria vectors suggests
a shift to greater outdoor biting in response to malaria interventions,7-9 deeper understanding of sleeping
and other nocturnal activities that commonly occur outside will become even more critical.
In Ghana, as in many other parts of Africa, malaria is the leading cause of morbidity and workdays
lost due to illnesses,10 and the number one cause of mortality in children under five.2 We are hopeful that
the methods proposed here will contribute to realizing the full potential of the tools we have for
preventing malaria – ITNs and IRS. In this way, we hope to confront one of the most intractable public
health challenges of our time and a disease that continues to disproportionately target the disadvantaged.
Yukyan Lam
IV.
Delta Omega Scholarship - Abstract
Budget and Other Support
Institutional support in Ghana will be provided by Johns Hopkins Center for Communication
Programs (CCP), which will provide me with work space during my time in Accra, facilitate contact with
in-country researchers, and cover the costs of in-country transportation and support for field workers. I
have applied for small grants from the International Health Department and the Center for Global Health
to cover part of the expenses. I have not received any notification about these yet.
The budget is as follows:
Airfare between Baltimore and Accra
Housing
Food
In-country transportation b/w data collection sites
Visa
Total
Amount requested from Delta Omega Scholarship
$1700
$1500 ($500/month for 3 months)
$450 ($150/month for 3 months)
$500
$60
$4210
$1000
V.
Bibliography
1.
Ghana Health Service (GHS) Ghana Statistical Service (GSS), and ICF Macro, 2009. Ghana
Demographic and Health Survey 2008. Accra, Ghana: GSS, GHS, and ICF Macro.
President's Malaria Initiative, 2012. Malaria Operational Plan - FY 2013. Washington, DC: United
States Agency for International Development, President's Malaria Initiative, Department of Health
& Human Services, Center for Disease Control and Prevention, United States State Department.
President's Malaria Initiative, 2011. Malaria Operational Plan - FY 2012. Washington, DC: United
States Agency for International Development, President's Malaria Initiative, Department of Health
& Human Services, Center for Disease Control and Prevention, United States State Department.
United Nations Children's Fund (UNICEF), 2007. UNICEF Ghana Fact Sheet Malaria. Accra,
Ghana: UNICEF Ghana.
Nkhoma ET, Kalilani-Phiri L, Mwapasa V, Rogerson SJ, Meshnick SR, 2012. Effect of HIV
infection and Plasmodium falciparum parasitemia on pregnancy outcomes in Malawi. American
Journal of Tropical Medicine and Hygiene 87(1):29-34.
Davidson B, 2012. Rapid survey of nighttime activity patterns among Ghanaian children using
Peace Corps Volunteers as community informants. Unpublished manuscript. Tamale, Ghana:
United States Peace Corps.
Reddy MA, Overgaard HJ, Abaga S, Reddy VP, Caccone A, Kiszewski AE, Slotman MA, 2011.
Outdoor host seeking behaviour of Anopheles gambiae mosquitoes following initiation of malaria
vector control on Bioko Island, Equatorial Guinea. Malaria Journal 10:184.
Moiroux N, Gomez MB, Pennetier C, Elanga E, Djènontin A, Chandre F, Djègbé I, Guis H, Corbel
V, 2012. Changes in Anopheles funestus biting behavior following universal coverage of longlasting insecticidal nets in Benin. Journal of Infectious Diseases 206(10):1622-1629.
Russell TL, Govella NJ, Azizi S, Drakeley CJ, Kachur SP, Kileen GF, 2011. Increased proportions
of outdoor feeding among residual malaria vector populations following increased use of
insecticide-treated nets in rural Tanzania. Malaria Journal 10:80.
Ministry of Health [Ghana], 2008. Ghana National Malaria Strategic Plan, 2008-2015. Accra,
Ghana: Ministry of Health [Ghana].
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