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A community-led program towards malaria elimination in the Eastern Province of Rwanda: Intervention mapping approach

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Title: Using an intervention mapping approach in planning, implementation and evaluation of a community-led project towards malaria elimination in the Eastern Province of Rwanda 

Chantal Marie Ingabire, Emmanuel Hakizimana Fredrick Kateera, Alexis Rulisa, Bart van den Borne, Ingmar Nieuwold, Claude Mambo Muvunyi, Constantianus JM Koenraadt, Michelle Van Vugt, Leon Mutesa, Jane Alaii

Intriduction

Malaria remains a major public health problem worldwide. The World Health Organization estimates about 3.2 million people to be at risk of malaria worldwide and in 2015, 89% of malaria cases and 91% of malaria deaths of the global malaria burden were located in sub Saharan Africa. Malaria elimination requires strategies that target the parasite, the vector and most importantly the human host, hence the community participation is a key factor. We describe the development, implementation and evaluation of an integrated community-based malaria elimination project (MEPR) in Ruhuha sector, Bugesera district, Eastern province of Rwanda using an intervention mapping (IM) approach.  MEPR consisted of four components: Behavioural sciences, biomedical sciences, medical entomology and health economics

Methodology

IM is defined as a systematic approach used in the development of health promotion program. Informed by theory, IM guides strategies for change that are linked to behavioral and environmental factors related to health outcomes. IM involves six steps; (1) a needs assessment, (2) design of a matrix of proximal program objectives, (3) selection of theory-based intervention methods and practical applications (4) design of the program, (5) adoption and implementation plans, and (6) program evaluation. The needs assessment in the current program included Open Space discussions, a stakeholder analysis, household and entomological surveys to inform systematic development of targeted project interventions for behavioural and environmental changes. Two project components were subsequently implemented, namely the establishment of community malaria action teams (CMATs) in mid-2014 as platforms to deliver malaria preventive messages at village level, and implementation of a mosquito larval source control program that used biological substances in neighboring marshlands and other water bodies for a duration of six months (January- July 2015). Both programs were followed by a process and outcome evaluation to inform future scale up 

Resultats

Step 1: Needs assessment

•Two open space meetings held in 2012 and 2013 to discuss on the role of community in malaria control and elimination.
•A stakeholder analysis conducted in 2013 generated a list of potential malaria actors who were further categorized into primary, secondary and key stakeholders.
•The baseline household survey conducted in 2013 followed by a series of focus group discussions highlighted a low uptake of malaria preventive measures due to various factors such as bedbug infestation of LLINs despite a high coverage (92 %) and perceptions that IRS activated mosquitos, rather than kill them. Only two-thirds of the population was found to have a CBHI at baseline while malariometric data showed 23% and 5 % of symptomatic and asymptomatic malaria prevalence.
•An entomological monitoring survey reported 46.4% and 3.3% Anopheles gambiae s.l. (main malaria vector collected) of the total mosquitoes collected in 2013 and 2014, respectively. However, a general increase in mosquito density was observed as opposed to a decrease of Anopheles gambiae density in 2013 and 2014 and an average of 18 and 35.3 mosquitoes per house surveyed was reported, respectively.

Step 2: Synthesis of determinants and defining change objectives

•Behavioral outcomes included promotion of malaria preventive measures such as (1) to increase the correct and consistent use of LLINs, (2) to accept IRS at household level including master and storage rooms, (3) to clear peridomestic mosquito breeding sites and (4) to promote prompt care seeking for fever cases by increasing awareness and recognition of malaria symptoms and CBHI ownership.
• Environmental outcome included the larval source control intervention in local marshlands and other peridomestic water bodies.

Step 3: Theoretical methods, practical applications and parameters for use

•Theoretical concepts that guided program implementation were defined and included the theory of planned behavior, theory of learning, self-regulation and the diffusion of innovation theory.
•Theories were applied through surveys, regular exchange and dissemination meetings.
•Parameters of use were awareness, beliefs, social support, self-efficacy and skills.

Step 4: Design of program components and materials

Two program components were deemed important:

•Firstly, the need to focus on behavioral aspects through community mobilization informed the establishment of community malaria action teams (CMATs) since mid-2014 with the aim to increase awareness on malaria preventive measures in the local community.
•Secondly, trained community members (mainly rice farmers’ cooperatives and CMATs) deployed an environmental intervention using biological substances “bacillus thuringiensis israelensis (Bti)” for mosquito larval control across mapped and newly identified breeding sites from February to July 2015.

Step 5: Program adoption, implementation and maintenance

In addition to identification of stakeholders to be engaged, the project recommended activities to be performed for adoption, implementation and maintenance of the project components:

•Community education through CMATs to be continued with regular support of local health centre
•The mosquito larval source control to be scaled up and not only involve local rice farmers but also the general community. Furthermore, the intervention need to be integrated into national vector control strategies.

Step 6 Process and outcome evaluation

A follow up household survey conducted in December 2014 indicated:

•39% of community members were visited by at least one CMATs member while 52% and 38% reported receiving messages on clearing peridomestic water dams and proper use of LLINs, respectively. At least 23%, 18% and 13% of the respondents reported receiving messages on early health care seeking, importance of a CBHI and the benefits of IRS, respectively.
•A slight increase of 1 and 5% in the coverage of LLINs and IRS and a high increase of 24% in CBHI ownership when compared to the 2013 baseline survey.

An end line qualitative study conducted in October 2015 highlighted:

•A general perception of reduction of malaria during MEPR attributed to the improved sensitization towards malaria control measures that contributed to an increase in community knowledge, acceptance and use of vector control strategies (LLINs and IRS) and increase in the coverage of CBHI.
•A reduction in adult mosquito density and nuisance generally in treated sites when compared to control site during the larval source control intervention.
•Challenges related to geographical and operational factors were however enumerated including heavy rains and deep and slippery marshlands that are hard to cover by manual application and inadequate staff during implementation, hence participants suggested that challenges should be taken into cognizance prior to future scale up.
•The need of stakeholder participation (communities and government ) in searching for strategies that aim at ensuring the  continuation of larval source management

Conclusion

This community-based program demonstrated the feasibility and effectiveness of active community participation in malaria control activities, which largely contributed to community empowerment and reduction of presumed malaria in the area. Further studies should explore how gains may be sustained for malaria pre-elimination.

References

Ingabire, C.,et al. (2014). Community mobilization for malaria elimination: application of an open space methodology in Ruhuha sector, Rwanda. Malar J, 13(1), 167.

Ingabire, C., et al. (2016). Determinants of prompt and adequate care among  presumed malaria cases in a community in eastern Rwanda: a cross sectional study. Malar J, 15(1), 227.

Ingabire, C.,et al. (2015) Factors impeding the acceptability and use of malaria preventive measures: implications for malaria elimination in eastern Rwanda. Malar J, 14(1), 136.

Ingabire, C., et al. (2016) Stakeholder engagement in community-based malaria studies in a defined setting in the eastern province, Rwanda Mediterranean Journal of Social Sciences, 7(2), 214-222.

Kateera, F., et al. Long-lasting insecticidal net source, ownership and use in the context of universal coverage: a household survey in eastern Rwanda. Malar J, 14(1), 390.

Kateera, F., et al., (2015). Malaria parasite carriage and risk determinants in a rural population: a malariometric survey in Rwanda. Malar J, 14(1), 16.

 

 

 

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