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HEALTH POLICY AND PLANNING; 14(4): 313–321
© Oxford University Press 1999
Implementing a malaria curtains project in rural Malawi
MARCIA RUBARDT,1 AUGUSTIN CHIKOKO,1 DEBORAH GLIK,2 STAN JERE,1 OKEY NWANYANWU,3
WEIYING ZHANG,2 WILFRED NKHOMA3 AND CHARLES ZIBA3
1Save the Children Foundation USA, Field Office, Mangochi, Malawi, 2UCLA School of Public Health, Los Angeles,
CA, USA, and 3Malawi Ministry of Health, Lilongwe, Malawi
This paper describes planning, implementation, monitoring and evaluation activities carried out in support
of a malaria control project that used permethrin-impregnated curtains in eight villages in rural Malawi. Findings from formative evaluation and project monitoring aspects of the evaluation are presented. Permethrinimpregnated curtains were introduced to villagers who participated in household self-help projects. To
implement the project, village health workers were trained and worked closely with existing project personnel as well as traditional headmen to assure village participation, facilitate health education and coordinate
curtain-dipping (impregnation) meetings. A quasi-experimental evaluation design used surveys and observations to measure change in cognitive, behavioural and health outcome indicators. Village adoption rates
averaged 50%, with variation between villages. Monitoring data showed a high degree of compliance with
curtain re-impregnation initially and high perceived efficacy of curtains. Issues discussed include village
readiness for change, trust, acceptability of the innovation, cost, sustainability and leadership.
Introduction
Many malaria prevention strategies in sub-Saharan Africa
promote mosquito control at household, neighbourhood and
community level.1,2 These strategies include preventive sanitation, the use of insecticide-impregnated bednets, curtains,
or wall cloths, and residual spraying of houses and public
areas.3–5 They have replaced large scale mosquito eradication
or chemo-suppression efforts, that have been shown to have
limited effectiveness as well as unanticipated consequences
such as increased parasite resistance to anti-malarial drugs, or
unacceptable levels of toxicity in environmental spraying.6,7
In this paper we report on planning, implementation and
process monitoring of an impregnated curtains project in
rural Malawi. In this intervention permethrin-impregnated
curtains were given to households in exchange for household
preventive sanitation self-help projects. The objective of this
exposition will be to describe the operational aspects of this
project and how principles of community development and
self-help can be used to implement this type of small-scale
mosquito control programme.
More widely used and documented than curtains, permethrin-impregnated bednets have been shown, when properly
used, to be highly efficacious in reducing human contact with
mosquito vectors, and morbidity and mortality related to
malaria.3,4,8–13 Community-wide distribution of impregnated
bednets, besides providing individual protection to the
persons sleeping under the nets, has been shown to decrease
the transmission of malaria by killing mosquitoes and thus
reducing the mosquito population, with some evidence suggesting a ‘mass effect’.
A less widely adopted strategy for malaria control is permethrin-impregnated curtains,14–17 impregnated screens,18 or
wall cloths.19 Evidence suggests that permethrin-impregnated curtains, screens and cloths also reduce malaria significantly in populations covered;15,18,19 however, the evidence is
not as strong as for bednets.4,17
If curtains have not been shown to be as efficacious as
bednets, why did we choose curtains rather than bednets for
this project? The answer is based on extensive formative
research carried out in villages prior to programme
implementation that suggested that curtains would be a more
sustainable intervention given cultural norms and preferences, cost and durability of materials. The implementation
of household-level mosquito control interventions is highly
dependent upon community participation; thus interventions
must be culturally appropriate and tailored to characteristics,
needs, demands and resources of communities.20,21
For implementation, this project drew heavily on some of
the basic principles of health development and community
organization at the village level.22 For example we used the
principle of ‘capacity building’ among village health workers
and volunteers, to encourage effective work.23,24 Another
principle was the ‘integration’ of malaria prevention activities with ongoing primary health care activities, 25 achieved
by building on a previous child survival project that had been
in place for a number of years. The antecedent child survival
project had hired and trained Health Surveillance Assistants
(HSAs), who had carried out comprehensive MCH health
education on immunization, diarrhoeal disease, nutrition
and breast-feeding as well as malaria treatment and prevention in villages and in primary health care clinics. The child
survival project also created village-based stocks of primary
care drugs for common childhood illnesses, purchased
through revolving funds, including stocks of sulfadoxine/
pyrimethamine (SP), the current recommended treatment
for malaria in Malawi.26,27
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Other principles utilized here are those of ‘leadership’,
‘empowerment’, ‘ownership’ and ‘trust’; in sub-Saharan
Africa working within the political power structure of tribal
chiefs or headmen. Finally the principles of ‘formative
research’ from the field of social marketing were used to
identify local definitions of malaria, community-defined
problems, social behaviours, target population needs and
potential incentives to participate.28–33 Results from formative research are described below.
Setting
Villages chosen to be in the study were all part of the Chilipa
area in the Mangochi district in south central Malawi. This
district, a plateau bounded by mountains, lies to the west of
the southernmost point of Lake Malawi. It is an isolated area,
approximately 30–40 km from the nearest large town. Villages vary in size from 150 to 300 households, and are clustered around a central area with fields surrounding household
compounds. Seventy percent of households had one or more
children under 5 years of age. The villages participating in the
study were chosen randomly, and all were at least 3 km distant
from one another. Poverty is high in this area, with villagers
engaged mainly in subsistence farming, with maize the principle crop. The economic system is one of freehold farming,
village headmen determining land use patterns. Generally
houses are small, with only one or two rooms and are made
of mud brick with thatched roofs. Only some houses have
windows, but many have high eaves that insects can enter,
which is also a consideration.
Villages are naturally stratified by ethnicity, with certain villages composed of 80–90% Yao ethnicity, and the other villages reporting 80–90% Ngoni ethnicity. The majority of
inhabitants are conversant in Chichewa. Malaria caused by
Plasmodium falciparum is endemic in the area, the presence
of mosquitoes assured by a 5-month long rainy season
between November and March. Malaria transmission rates
are highest just following the rainy season in April and May,
based in the incubation and hatching periods for mosquito
larvae Anopheles gambiaie, which is the major mosquito
vector in this area.
Programme planning
Formative research using focus group interviews as well as
observations of community health workers (HSAs) were
used to help plan strategies for community mobilization, communications, curtains measurement and distribution, and the
evaluation research design. Sixteen focus group interviews
among adults, two in each of the eight villages, were conducted. Groups were stratified by gender and conducted in
Chichewa. Open-ended questions included experience with
malaria, knowledge of malaria transmission, local terminology used for malaria, malaria prevention and mosquito
control methods, costs of malaria drug treatments, availability and acceptability of curtains in homes, and colours and
materials preferred for curtains. The concept of permethrinimpregnated curtains was discussed and focus group participants asked if they would like curtains, and what self-help
projects they would do to obtain curtains. Interviews were
tape-recorded, transcribed verbatim, translated from
Chichewa into English, content coded and analysed to
uncover common themes.34
Findings from these focus groups indicated community readiness for this intervention. Villagers’ experience with malaria
was profound, all groups reporting this as one of the most
serious diseases, particularly for young children. Knowledge
of malaria transmission by mosquitoes was high, a finding
later confirmed in the baseline survey where 82% of respondents responded that malaria is caused by mosquitoes. Attribution of causality from mosquitoes did not rule out other
causes such as cold weather and poor hygiene. Knowledge of
the causal role of mosquitoes in this population suggests that
HSAs were effective health educators in these communities.
It should be noted that there had been a national communications campaign in 1993, stressing the recommended treatment for malaria, sulfadoxine/pyrimethamine (SP), as well as
the role of the mosquito vector.
Respondents revealed that they did a large amount of work
to rid their houses of mosquitoes, using both preventive sanitation and traditional methods such as burning leaves and
herbs, and smearing cow and goat dung on houses. These
labour intensive methods were not perceived as very effective, however, and respondents complained about frequent
bites. Examples of responses are:
• “These methods help a little bit.”
• “It is difficult to prevent the mosquitoes biting us because
during the rainy season we plant maize near the houses
where mosquitoes breed.”
• “We burn green grass in the house, then the smoke runs
away the mosquitoes. If smoke is over then mosquitoes bite
us.”
• “We chase them from our houses with cloth.”
Moreover few could afford to buy commercially marketed
mosquito control methods even though these were perceived
as effective. Some respondent remarks are:
• “We don’t have money to buy mosquito nets.”
• “Those who have a lot of money sleep under mosquito nets.”
• “Because of poverty here we cannot get mosquito nets so
the mosquitoes keep on biting us.”
• “Coils are expensive.”
Lack of access to bednets was confirmed in the later baseline
survey, where only 3% of the households asked reported that
they used bednets.35
Respondents easily grasped the impregnated curtain concept,
and based on a direct translation of the term in Chichewa, the
name ‘Medicine Curtains’ became the project nickname.
Points of acceptance of medicine curtains were that respondents reported that they already covered windows and doors
with other materials such as reeds, mats, wood, and sometimes glass windows for privacy and security and to keep out
insects. Villagers also reported that curtains were a status
symbol and were observable from the street (enhancing
household status), they could protect the entire household
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315
not just those who slept under them, and they were perceived
to be more affordable and durable than bednets, as bednets
could tear especially if tucked into floor mats with rough
edges. Observations by HSAs confirmed that children mainly
sleep on the floor on mats rather than on beds.
curtain use, such as waiting to wash, keeping curtains closed at
night, and scheduling 6-month reimpregnation sessions. Community meetings, word of mouth and interpersonal contacts
comprised communications strategies, as the villages are closeknit, isolated, and have low literacy rates.
Points of resistance to medicine curtains were questions
about the toxicity of treated curtains for insects and persons,
social desirability of curtains enticing thieves to steal the
curtains, issues of cost and access, given their lack of money.
Villagers were very willing to do household preventive sanitation self-help projects to acquire curtains free of charge,
and most were willing to work two days per week clearing
brush, emptying stagnant pools, clearing rubbish for collective sanitation projects.
The HSAs also supervised the initiation of self-help preventive sanitation projects carried out by householders in
exchange for curtains. Household projects included building
pit latrines or kitchen outbuildings (to reduce fires in houses),
digging drainage ditches, clearing and burning or burying
rubbish, and clearing brush away from the house. For households whose projects qualified them to receive curtains,
houses were measured, cloth acquired, curtains sewn and
impregnation sessions held continuously between December
1995 and March 1996. In all, 740 households in intervention
villages received curtains, and an additional 180 persons from
non-intervention villages bought materials for curtains or
brought old curtains for impregnation.
Programme implementation
The model for implementation of impregnated curtains in
this area was mass distribution with community-based
support, rather than private sector or employee-based marketing or distribution.21 Initial start-up costs of hiring community workers, procuring materials, measuring houses,
sewing curtains, curtain impregnation and installation were
underwritten by the project. To assure sustainability, a costrecovery system to encourage villagers to organize their own
permethrin redipping sessions was established.
At baseline (September 1995) each intervention village had
an HSA, a paid paraprofessional with primary school education who lived in the village and promoted a range of child
survival activities. In addition, other village health workers
included a village health committee, a literacy instructor, a
traditional birth attendant, and an HIV/AIDS and family
planning motivator. These individuals, in addition to the
village headman, were contacted and asked to select a paid
‘malaria helper’ for the project, a person who would work
closely with the HSA on the malaria curtains project. The
malaria helper and the HSA were responsible for mobilizing
the village members to participate in the project, and worked
closely with village headmen to call meetings to meet project
goals and requirements. Malaria helpers were trained with
HSAs over a 5-day period on malaria treatment, prevention
and control. They were then joined by 24 enumerators for a
3-day training session on implementation of the project baseline household survey. HSAs and malaria helpers were team
leaders for each village-based survey.
Communications with villagers regarding the project reflected
the different stages of programme implementation. After completion of the baseline survey in October 1995, initial village
meetings from November through December 1995 included
informational messages to discuss mosquito control generally,
cost and benefits of the medicine curtains programme, projects
that persons could do that would qualify as ‘self-help’, and the
processes that obtaining curtains would entail. From the
period of December 1995 through March 1996 messages communicated were mainly logistic and technical and included
quantity of work completed, house measuring, sewing, impregnation and installing. Finally, after installation, messages
became motivational to increase compliance with correct
Logistic issues having to do with materials procurement,
measuring, sewing, impregnation and hanging curtains were
supervised by the Project Coordinator and central office staff.
Due to market price increases for cloth at the time of this
project, the first 100 households in each village who completed a self-help project received curtains. This created an
artificial ceiling on the percentage of households in each
village who could get curtains. As not all households in each
village wanted to participate, most persons who initially
wanted curtains got them. Later, as the perceived efficacy of
curtains became apparent, persons who did not get curtains
felt that this distribution policy was inequitable.
Village tailors were hired on a piecework basis to sew curtains. Curtains for windows, doors and vents were made from
medium-weight cotton. For open eaves a slightly lighter mesh
fabric was used to keep airways open, which had the advantage of not needing as much permethrin solution. Permethrin
was acquired in bulk and diluted to a 0.08 molar solution per
square metre of material. When curtains were ready for
installation, community dipping in centralized buckets was
organized. A 25% emulsifiable concentrate of permethrin
was diluted in 30 ml/l of water for the cotton dipping solution
and 35 ml/l of water for the net dipping solution to give a net
concentration of 0.5 g of active ingredient per square metre of
cloth or netting.
At least three initial impregnation sessions were held in each
village as people were also getting their curtains at these
times. People were mainly satisfied with the bright print
material they received. The uniformity of cloth colours was
fortunate: it became a clear observable indicator of participation in the project. Follow-up re-impregnation sessions
were held in June and July 1996, and then in December 1996
through February 1997. Re-impregnation cost villagers about
15–20 Malawi Kwatcha (MK), or $1–$1.20. There was dropoff between the three 6-month impregnations, with 100%
compliance at Time 1, 89% at Time 2 and 53% by Time 3, 12
months into the project period. This may impact on overall
outcome efficacy as permethrin is only effective for 6 months.
It should be noted that later dipping sessions were managed
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completely by villagers, not project staff, an intentional strategy to create a sustainable intervention.
Logistic issues of note are the high price of cotton cloth, which
drove up the cost of the intervention. Cost per household was
about $28 (about 420 MK); however, $26.50 reflects the cost
of the cloth: the remaining $1.50 covered the cost of the tailor,
installation materials, dipping materials, and permethrin.
Another issue is timing of impregnation. Ideally it should be
during the rainy season (November through March) when
malaria transmission rates are starting to rise; however,
people generally did not have money until after the harvest
(June/July).
Research and evaluation
To measure intervention impact on participants, a comparison group quasi-experimental pre-test/post-test design was
conducted in 12 villages (eight intervention, four control).
Results tested effectiveness of the intervention as well as
monitoring rates of adoption and change over time in attitudes, beliefs and behaviours. Baseline and outcome results
are reported elsewhere.36 In this paper, evaluation design elements are described as they were an integral aspect of this
community-based intervention, and one of the main tasks of
HSAs was to lead teams of enumerators at specified times to
collect evaluation data. Results from project monitoring of
intervention villages will be presented.
For the non-equivalent comparison-group evaluation design,
whole villages not respondents were randomly assigned to
treatment or control conditions. Moreover, random assignment of individuals within villages was not feasible given the
requirement that recipients volunteered for self-help projects. Thus we took a universal sample of all households from
each village, and then compared adopters with non-adopters
in intervention villages. This type of quasi-experimental
design is appropriate in situations where individual random
assignment is not possible.37
Weaknesses inherent in the design were compensated for by
building in design controls. In the case here, we used multiple
intervention and control villages with a range of characteristics, namely villages with higher or lower malaria rates and
villages with higher or lower socioeconomic status (see Table
1). In addition, certain information (household observations,
village monitoring) was collected at 6-month intervals to
monitor changes over time in the intervention villages, not
just at the beginning or the end of the study, a further means
of compensating for non-randomization (see Figure 1).
At baseline, all households in intervention and control villages were enumerated, and were administered KAP and
household observational questionnaires, with an approximate 95% response rate. Six-month monitoring of intervention villages included observations of households to assess
participation in the intervention. As well, biological screening
for malaria positivity and parasite density for children under
5 years old was carried out using fingerstick blood samples at
baseline and at outcome and, for the intervention villages, at
the 6-month monitoring intervals. At baseline all children
from 6 months to 5 years of age in control and intervention
villages were given a presumptive dose of SP for malaria to
assure that there was equity in biological markers between
intervention and control villages.
To measure programmatic impact directly, respondents surveyed at baseline were followed up by the outcome survey
conducted 18 months after the baseline. If the intervention
was effective, changes in the intervention village populations’
behaviour (e.g. number of households using impregnated curtains as well as changes in parasite prevalence in under 5 year
olds) were expected to be detectable between each village’s
baseline survey point (Time 1) and its post-intervention
survey (Time 4). Additionally, there should be differences
between adopter and non-adopter households within intervention villages.
Villagers’ perceived efficacy of project
Results from monitoring surveys carried out in eight intervention villages are presented in Tables 1–4. In Table 1, it can
be seen that rates of adoption varied by village, with four villages having adoption rates of over 50%. One village was
below 25%. It should be noted that, in general, villages with
highest adoption rates were those who had higher rates of
malaria. Village level socioeconomic status did not seem to be
a factor; however, there were relatively small differences
Table 1. Adopters and non-adopters by intervention village at Time 2
Village
1. Mwatakata
2. Matenje
3. Nikisi
4. Chalenga
5. Mitawa Midondo
6. Naunje
7. Mtendere
8. Mkaweya
Adopters
n
Non-adopters
n
%
SES level
Malaria level
%
64
100
124
118
100
100
100
100
21.5
38.6
52.3
50.6
42.9
63.6
67.5
44.6
187
182
113
125
131
57
48
124
lower
lower
higher
lower
higher
lower
higher
lower
higher
lower
higher
higher
higher
higher
higher
lower
78.5
61.4
47.7
49.4
58.1
37.4
32.5
55.4
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In Table 4, adopters and non-adopters are compared on indicators of perceived efficacy of medicine curtains. Scores are
significantly higher among adopters, and both adopters and
non-adopters report that medicine curtains reduce the number
of mosquitoes and also that they killed mosquitoes. There are
significant and consistent differences between adopters and
non-adopters on three indicators: noticing fewer mosquitoes in
the household, family members complaining less about mosquito bites, and family members experiencing fewer malaria
attacks. For these responses there is an inverse set of responses
for adopters compared to non-adopters, with chi-squares and
odds ratios all highly significant at the p < 0.0001 level. Perceived efficacy for curtains is high, especially among those who
have curtains. It should be noted that the Time 2 monitoring
survey was done at the peak of the malaria season in April and
May so that questions are particularly relevant to respondents.
However these perceptions of efficacy continue to remain at
Time 3, six months later, at the end of the dry season when
malaria transmission is relatively low (October) and many
months after the initiation of the intervention.
Figure 1. Research and evaluation design
between higher and lower SES villages in this context. Villages with higher acceptance rates had more dynamic village
leadership.
In Table 2, questions relating to the experiences of adopters
are presented. Essentially all curtains had been distributed 6
months after the baseline survey, and in Year 1 of the project
compliance with impregnation and re-impregnation as
reported here seems to be high. However re-impregnation
rates by Time 3 were starting to drop off, to some extent due
to the time of year (December before planting) when households have very little disposable income with which to pay for
re-impregnation.
In Table 3 perceptions of non-adopters are presented. The
most common reason for non-adoption was the difficulty of
fulfilling requirements of a self-help project. As stocks of curtains were no longer available except by buying them at the
end of Year 1, these perceptions intensified. However, at both
6-month (T2) and 12-month (T3) follow-up, the majority of
non-adopters, 85.4% and 86.1 respectively, said they planned
to get curtains in the future.
Table 2.
After the Time 3 monitoring surveys, 10 focus groups were
also carried out in four intervention and two non-intervention
villages to assess: the distribution and use of medicine curtains, advantages and benefits of using medicine curtains,
changes in mosquito control measures, current demand for
new curtains, re-impregnation and sustainability of the
project. Groups were stratified by adoption (adopters and
non-adopters) for intervention villages and only adopters for
non-independent villages. Findings mainly confirm what was
reported for Time 3 monitoring surveys.
Respondents indicated that the objectives and the requirements for getting curtains were well explained. Also the work
for which was curtains were received was considered a fair
exchange. Both adopters and non-adopters reported that
medicine curtains had the following benefits: kill mosquitoes,
reduce malaria, kill other insects such as bedbugs and cockroaches, promote a good night’s sleep and reduce mosquito
bites. Moreover, no side effects of medications were noted
either in surveys or in focus groups.
Respondents also revealed that they were using more preventive sanitation mosquito-control measures and fewer traditional methods such as burning leaves, or smearing cow
Perceptions of adopters at Times 2 and 3
How long have you had curtains?
In the past six months have you:
received curtain? (yes)
dipped or redipped curtain? (yes)
received advice? (yes)
Do you:
close curtain at night? (yes)
redip at six months? (yes)
redip all curtains? (yes)
Time 2
Time 3
4 months average
n
%
9 months average
n
%
655
611
638
96.6
90.1
94.1
18
622
687
2.6
89.2
98.6
635
562
622
95.5
84.9
92.9
642
611
608
92.1
87.7
89.1
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Marcia Rubardt et al.
Table 3. Perceptions of non-adopters at Times 2 and 3
Why did you not get curtains?
Too much money
Too hard to get
Too much work
Don’t want to cover eaves
Mosquitoes not a problem
Have not heard about it
Other
Do you plan to get curtains?
Yes
No
Maybe
Don’t know
Time 2
n
%
Time 3
n
%
35
264
231
4
1
20
–
6.3
47.6
41.6
0.7
0.2
3.6
–
127
394
142
8
1
20
–
18.4
56.0
16.4
1.2
0.1
2.9
–
656
74
23
34
85.4
9.4
2.9
4.3
744
83
30
4
86.1
9.9
3.6
0.5
Table 4. Perceived efficacy of medicine curtains between adopters and non-adopters Time 2 and Time 3
TIME 2
––––––––––––––––––––––––––––––––––––––––––––––––––––
x2
OR (CI)
Adopters
Nonadopters
(sig.)
TIME 3
––––––––––––––––––––––––––––––––––––––––––––––––––––
Adopters
Nonx2
OR (CI)
adopters
(sig.)
Do medicine curtains reduce the no. of mosquitoes?
Yes
682 (94.6)
698 (93.4)
38.3***
8.6 (2.8, 25.7)
660 (98.4)
No
39 (5.4)
49 (6.6)
11 (1.6)
Do medicine curtains kill mosquitoes?
Yes
677 (98.7)
727 (96.2)
8.9**
2.0 (1.1, 3.6)
650 (97.9)
No
9 (1.3)
29 (3.8)
14 (2.1)
Have you noticed fewer mosquitoes in your house in the last 6 months?
Yes
655 (97.3)
91 (12.5)
1010.77***
31.9 (20.2, 50.4) 663 (96.4)
No
18 (2.7)
637 (97.5)
25 (3.6)
Do family members complain less about mosquito bites?
Yes
582 (86.4)
131 (17.4)
676.9***
6.3 (5.21, 7.7)
654 (94.3)
No
92 (13.6)
622 (82.6)
37 (5.4)
In your household, has there been less malaria among family members in last 6 months?
Yes
650 (96.6)
114 (15.0)
953.48***
24.7 (16.5, 36.9) 659 (95.8)
No
23 (3.4)
645 (85.8)
29 (4.2)
485 (92.9)
37 (7.1)
22.57***
2.5 (1.5, 4.23)
513 (94.3)
31 (5.7)
10.74*
1.79 (1.2, 2.8)
63 (7.8)
747 (92.2)
1168.9***
28.2 (19.2, 41.5)
54 (6.6)
770 (93.4)
1171.6***
20.1 (14.7, 27.6)
49 (6.0)
763 (94.0)
1203.8***
25.4 (17.7, 36.3)
* p < 0.01, ** p > 0.01, *** p < 0.001
dung, as well as fewer commercial methods such as the use of
insect-repellent coils. All expressed concerns about the high
cost of getting new curtains, which was a potential barrier for
those who did not yet have curtains. While all respondents
reported that they wanted to re-impregnate curtains, they
perceived the cost of 15–20 MK (about $1–$2) as high.
have changed their mosquito control behaviours, and feel it is
important to acquire and re-impregnate curtains. They were
supportive of the project but are concerned about the cost of
buying new curtains and re-impregnation.
Respondents reported that they wanted the project to continue and that the responsibility of mosquito and malaria
control was in the hands of everyone in the village. They also
expressed the view that the village headmen and village
health team should be responsible for organizing the
impregnation and running the project. However, the cost of
buying materials for curtains and re-impregnation as well as
providing sufficient permethrin were constraints on sustainability.
In this paper we have described the planning, implementation, and evaluation of a community-based permethrinimpregnated curtains intervention in rural Malawi to control
mosquitoes. We have also presented formative research and
project monitoring results. At baseline, villagers had a relatively high understanding of mosquitoes as the vector in
malaria transmission, and were already carrying out many
activities to control mosquitoes. However they perceived
many of these measures as ineffective. Villagers received
curtains if they committed to and completed preventive sanitation self-help projects in their households. Adoption of permethrin-impregnated curtains in eight intervention villages
Conclusions based on these findings were that people in the
area have seen or heard the benefits of medicine curtains,
Discussion
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Malaria curtains in rural Malawi
averaged 50%, which was due to initial interest by some and
not others and the lack of availability of cloth for all households who eventually sought curtains.
Community-based activities carried out by village-based
workers included informational meetings as well as community impregnation sessions for those who qualified or had
curtains. At 6 and 12 months after initiation of the project,
households with curtains, in contrast to households without
curtains, expressed higher perceived efficacy for mosquito
control. Concerns were expressed, however, about the high
costs of dipping and what would happen if they wanted to
replace curtains. Those without curtains complained that the
distribution was inequitable, but planned to get curtains if
they were available at low cost.
While the evaluation design is a somewhat complex and timeconsuming aspect of this project, HSAs and malaria helpers
were effective team leaders in implementing the evaluation as
well as the intervention. Extensive training received prior to
project implementation and periodic updates before each
data collection activity has helped. Villagers have been
cooperative in answering questions and letting enumerators
into households to observe curtains. Both enumerators and
malaria helpers are from the villages and thus they are well
known in the community. The HSAs are helped in this
endeavour by being in charge of the villages’ revolving drug
funds, and hence are trusted and important members of the
community.
When assessing the preliminary results presented here, it is
suggested that this intervention has been relatively successful
in intervention villages. Village characteristics played a role
as they lie in a relatively isolated area of Malawi and as such
have intact social structure and strong traditional governance
systems. When village headmen became project supporters,
villagers were more likely to volunteer to do self-help projects
and to get curtains.
As noted elsewhere, the trust of villagers is important in
community-based programmes.20 The NGO running the
project had a positive history in the community of building
up the health infrastructure and increasing the capacity of
health workers through an ongoing child survival programme, as well as other ongoing programmes for HIV/
AIDS and family planning. Thus this project built on an
ongoing positive relationship between the donor agency and
the communities.
The intervention itself had characteristics that made it
appealing and acceptable to villagers. Based on diffusion of
innovations theory,37 the innovation (permethrin-impregnated curtains) was culturally compatible, had observable
outcomes, had the relative advantage of being an alternative
to more cumbersome traditional means of burning leaves and
smearing dung, was perceived to kill mosquitoes, and was a
relatively simple concept to communicate to villagers. Moreover the logistic issues of buying cloth, measuring, sewing,
dipping and installing were relatively straightforward and did
not require a high degree of technical expertise. Finally curtains were associated with the maintenance of privacy and
319
were considered a sign of social status, similar to findings
about bednets.21
The difficulty with this innovation was twofold. Firstly, not
all villagers were able to get curtains, which caused some
hard feelings among the have-nots. As has been found elsewhere, those who participate in development projects are
often the higher status and wealthier members of the community.38,39 This fits with diffusion theory which states that
early adopters tend to be of higher status. 37 If we consider
those who got curtains as early adopters or early majority,
they may indeed be more integrated into the village hierarchy than those who did not get curtains. As everyone in
these villages was quite poor, wealth may not be the differentiating factor. The other factor that made a difference was
dynamic village leadership, which in a sense can be considered a differential village resource.
The other main drawback was the initial high expense for the
cloth, too high for most villagers. While there were people in
villages with skills to fabricate curtains and to organize
impregnation sessions, whether there will be a demand for
curtains after the project ends is doubtful. As noted, it was the
cost of the cloth that was exorbitant, not the permethrin,
sewing or installation. Follow-up focus groups revealed moreover that cloth did not go unused in these villages: cloth was
worn until it fell apart so used cloth was not an alternative.
Thus sustainability in poor rural areas is dependent on subsidization of cloth. Interestingly, the implementation of this
project has spawned great interest in acquiring such curtains
in nearby wealthier towns among salaried employees, where
it can be anticipated that a cottage industry for impregnated
curtain production could be developed. Thus the preception
of this innovation may differ in populations that can afford a
cash outlay.
Another sustainability issue is continuance of permethrin
impregnation, a cumbersome and time-consuming process at
the village level. Permethrin was only available in bulk quantities so redipping had to be collective, and procurement was
dependent on the donor agency. By the second year of the
project there was a drop-off in compliance with re-impregnation of curtains, which may seriously compromise their
efficacy. As focus group respondents suggested, the time of
the dipping should coincide with the start of the malaria transmission season. Perceptions of malaria and motivation to
comply may be higher at this time.20,40 If villagers cannot
afford to pay for the cost of the permethrin to dip curtains at
this time of year, when crops are in the ground but not yet harvested, establishing a revolving fund or credit system at
village level for permethrin is possible. However, in contrast
to the cost of cloth, the fully unsubsidized cost of permethrin
dipping is affordable at the village level.
In sum this project facilitated implementation of an innovative solution for mosquito control. In this project adoption
and perceived efficacy rates were high, despite the poverty
and marginalization of target villages. Despite logistic
barriers, permethrin-impregnated curtains may be a viable
mosquito control solution in many areas in sub-Saharan
Africa.
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Acknowledgements
This study was funded through a grant from the USAID-Malawi
(Promoting Health Interventions for Child Survival, No. 612 – 0231)
to the Save the Children Federation (USA), Malawi.
Biographies
Marcia Rubardt is a nurse with a Public Health degree from Johns
Hopkins and 20 years experience working primarily in Africa, Latin
America, and domestic programmes. At the time of the study, she was
the programme officer for the Mangochi office of Save the Children.
She is currently working internationally as an independent consultant.
Augustine Chikoko is a Malawian nurse midwife who was employed
by Save the Children to coordinate the malaria curtains project. He
continues with Save the Children as project coordinator for a Ministry of Health capacity building project.
Deborah Glik is on the faculty of the UCLA School of Public Health.
She specializes in the assessment and evaluation of educational and
community-based projects and has over 20 years of experience in conducting research on health behaviour change, health communications,
321
formative research and programme evaluation in a variety of settings,
having worked in both domestic and international arenas.
Stan Jere spent 30 years working with the Ministry of Health in
Malawi including serving as head of Maternal Child Health at the
national level during the early development of that department. He
subsequently spent 10 years with Save the Children coordinating
health projects in Malawi.
Dr Okey Nwanyanwu is an epidemiologist with a specialization in
malaria. In Malawi he worked for the Centers for Disease Control
for 7 years to improve both epidemiological and prevention research
efforts. He is currently working with USAID in Mozambique.
Weiying Zhang is a biostatistician who recently received her Masters
degree from the UCLA School of Public Health. She currently works
for the Rand Corporation in Santa Monica, California.
Dr Wilfred Nkhoma received his Public Health degree from Tulane
and returned to become Controller of Preventive Health services
where he has served for 4 years. He began his career as a clinical
officer in rural Malawi.
Charles Ziba is a clinical officer in Malawi who spent many years as
the Coordinator of the National Malaria Control Program for
Malawi.
Correspondence: Dr Deborah Glik, UCLA School of Public Health,
PO Box 951772, Los Angeles, CA 90095-1772, USA.