Running head: MALARIA IN KENYA

Insecticide Treatment Net Use in the Reduction of Malaria in Kenya, Africa

Larisa Anojahatlo, Leah Aragon, George Daniel, Chelsea Eggert,
Paige Nicolosi, Megan Rocha, and Nikki Thao
California State University, Stanislaus

Insecticide Treatment Net Use in the Reduction of Malaria in Kenya, Africa

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First documented over 4,000 years ago, malaria is an infectious vector-borne disease that
is transmitted to humans and animals by mosquitos (Centers for Disease Control and Prevention
[CDC], 2010c). This disease is associated with symptoms such as fever, chills, sweats,
headaches, nausea and vomiting, body aches, and general malaise (CDC, 2010b). Roughly half
of the world's population is at risk for contracting malaria (World Health Organization [WHO],
n.d.). The disease is present in Asia, Latin America, the Middle East, and parts of Europe;
however, most cases of malaria and subsequent mortalities occur in sub-Saharan Africa (WHO,
n.d.). Due to the high prevalence of malaria in sub-Saharan Africa, particularly in the state of
Kenya, we propose a malaria control program focused on the concept of primary prevention.
The main objective in fulfilling this model of prevention is to ultimately increase the percentage
of individuals who properly utilize and maintain their insecticide-treated bet nets (ITNs), which
act as physical and chemical barriers against mosquitos who transmit the infectious disease.
(CDC, 2014b). With this goal of primary prevention in mind, the long-term impact of the
program would be that there would be a decreased incidence of malaria in targeted program
areas. This program proposal will thoroughly address its goals, objectives, strategies, and
evaluation methods, all the while utilizing current research and findings as evidence to support
program plans and interventions.
Executive Summary
Malaria is a prevalent epidemiological issue in the African state of Kenya (WHO, 2013).
It is a disease that has claimed the lives of more than 46,000 Kenyans in 2013 alone and has
become an economic threat to the African state (Gathura & Kibet, 2014). Such a problem must
be addressed by promoting and increasing the proper use of ITNs as a way to combat the spread
of malaria in Kenya. With that said, our proposed project seeks to ultimately reduce the
incidence of malarial cases by increasing the percentage of individuals who properly use and

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maintain their household ITNs. A logic model has been written in order to outline our program
goals and plans of action in fulfilling our objective (Appendix B). To accomplish this long-term
impact, it is important to provide volunteer educational sessions among Kenyan communities,
including teachings of the dangers of malaria, its disease process, and ways to prevent
contracting the disease. One especially important education topic would include teachings for
proper maintenance and use of ITNs in order to combat the transmission of the infectious
disease. An advantageous outcome of providing such teachings is that it would ultimately help
reduce deaths due to malaria in certain endemic regions in Kenya.
Background
The CDC (2014a) has stated that Malaria is a leading cause of death and disease in
many developing countries, especially in African countries such as Kenya (Statistics section,
para. 1). The majority of malaria-related deaths occur in young children and women who are
pregnant. Plasmodium falciparum is the most deadly protozoan parasite in Kenya and is
predominantly responsible for severe malaria and death (CDC, 2014a, Geography section,
para. 4). Anopheles gambiae is the predominant species of mosquito that is primarily responsible
for the high transmission of P. falciparum. In addition to the morbidity and mortality woes of
malaria, there are also socioeconomic implications for combating this disease. Malaria inflicts
sizable costs to infected individuals and governments. Such costs related to malaria include the
purchase of treatment medications, the cost of clinic utilization, and expenses for burial and
ceremonial services following death. In the long-run, governments face economic woes such as
the inadequate staffing of healthcare facilities, the purchase of medications and medical supplies,
loss of income of individuals due to sickness-related work absences, and the reduction of tourism
due to fear of contracting the disease (CDC, 2014a).

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In combating the spread of malaria in Kenya, ITNs have been previously distributed to all
age groups since 2006 (WHO, 2013). In addition, preventative interventions such as intermittent
preventive therapy for pregnant women and the recommended use of indoor residual spraying of
insecticides have been previously implemented (WHO, 2013). However, funding for ITNs and
other malaria control and prevention interventions have been threatened due to economic
situations in which affordance of these interventions is problematic (CDC, 2014b). The CDC
claims that increasing the lifespan of ITNs can save on costs of malaria prevention programs and
sustain net coverage (CDC, 2014b). In support of this claim, one of the goals of our program is
to educate on proper maintenance of ITNs, which may increase the lifespan of the nets.
Literature Review
Before designing a public health program, it is beneficial to review previously-published
research on the topic of anti-malarial ITN implementation. The following are pertinent reviews
that provide clinical evidence that support the use of ITNs among regions stricken with malaria.
A retrospective cohort study was done by collecting admission data of pediatric patients
infected with malaria from five hospitals in Uganda from January 1999 to December 2009
(Okiro et al., 2011). The results revealed that an increase in mean malaria admission rates was
found in four out of five hospital sites. Overall, malaria admission rates had risen from 47% in
1999 to 350% in 2009. The use of ITNs increased from <1% in 1999 to 33% by 2009.
However, only two of the hospitals used nationally-recommended antimalarial drugs. These
results demonstrate that even with increases in prevention methods, certain areas in Africa are
still at risk for high malaria transmission without the increased use of effective drug treatment
(Okiro et al., 2011).
Chuma, Okungu, Ntwiga, and Molyneux (2010) conducted a study in four distinct
malaria endemic districts located in Kenya. The study was conducted to identify barriers to

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ownership and use of ITNs among the poorest populations in Kenya. According to the study,
ITNs are known to be most effective in preventing malaria. However, making sure that poor and
vulnerable populations are actually benefiting from malaria preventative measures remains a
challenge (Chuma et al., 2010).
Key findings of this study revealed that the prominent barrier to access of ITNs was
affordability (Chuma et al., 2010). Barriers to affordability included both the actual cost of the
ITN and time lost from work by having to buy or wait for a net after commuting to a net
distribution center. Discrepancy between the different types of ITNs provided and ITNs that the
community preferred was also an identified barrier. Although ITN preference varied among the
communities, non-white round nets were generally preferred because white nets became dirty
much quicker and were associated with misfortune, while rectangular nets were said to resemble
coffins. Other non-financial barriers to ITN access identified included community beliefs
regarding what caused malarial illness, where ITN suppliers were physically located, distrust
regarding free delivery, and distrust toward distribution agencies. Although barrier to
affordability can be addressed by providing free ITNs to the vulnerable population, the only way
these interventions can be successful is by addressing non-financial barriers to access as well
(Chuma et al., 2010).
A qualitative, cross-sectional study that investigated the effectiveness of integrated
malaria management (IMM) in the Mwea Division of Kirinyaga district in Central Kenya was
performed by Okech et al. (2008). The community's knowledge of malaria, including its
symptoms and treatment, were also assessed. A total of 389 homes in the community were
selected using a randomized cluster sampling method from a list of households in Mwea
Division. These households were then surveyed with a knowledge, attitude, and perception
(KAP) survey, The results of the KAP survey revealed that 97% of the interviewed households

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went to a health center for malaria diagnosis and treatment. This information is vital because
documenting cases of malaria at the local community hospital is the gage used to determine the
efficacy of IMM in this community. Almost 90% of households reported owning and using an
ITN as a part of IMM. This result included 81% of households that reported purchasing their
ITNs in the last 5 years. Efficacy of IMM had been demonstrated in which recorded cases of
malaria in the community hospital were reduced from about 40% in 2000 to less than 10% in
2004. Documented cases of malaria were eventually reduced to 0% by 2007. The data presented
in this study is extremely relevant to the idea of malaria prevention through the use of ITNs,
since a high percentage of the community that utilized their nets were interested in treating their
ITNs with insecticides to promote their effectiveness (Okech et al., 2008).
Despite the efforts to manage long-term uses of ITNs among Kenyan communities, the
effective lifespan is affected due to physical damages and the loss of insecticide activity (Mutuku
et al., 2013). Mutuku et al. (2013) underwent a study to identify and describe some of the
leading factors of poor physical conditions of bed nets owned by individuals in coastal Kenya. A
qualitative, community based cross-sectional survey was done between December 2009 and
April 2010, in which a designed questionnaire was used to collect data from eight different
villages. A total of 1,360 households were randomly selected for the survey. The questionnaire
addressed aspects that determined an effective bed net versus an ineffective one, as well as the
knowledge of the community individuals in caring and maintaining the insecticide nets (Mutuku
et al., 2013).
The results of the study revealed that of the 2,786 nets being utilized by individuals
within the community, 66% of the nets were being routinely used, while the remaining 34% were
not (Mutuku et al., 2013). The nets that were not routinely used were misused, damaged, or
considered extra nets. More importantly, the results demonstrated that there was a lack of
knowledge among the community in regards to maintenance and re-treatment of insecticide nets.

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It was reported that 69% of the nets had never been re-treated and were the longest lasting
insecticide nets. The remaining 31% were non-long lasting insecticide nets. The study shows
that due to the lack of access to insecticides and the lack of knowledge of how to re-treat the net,
there is a need to monitor and repair damages of the net, as more than 78% of all the ITNs
surveyed had holes or were torn (Mutuku et al., 2013).
Kahn et al. (2012) implemented a "community integrated prevention campaign" to reduce
the incidence of malaria, HIV, and diarrhea in Western Province, Kenya in 2008 (p. 1). This
campaign worked with 47,000 Kenyans over a one-week period by providing "HIV testing and
counseling, water filters, insecticide-treated bed nets, and condoms" for individuals (Kahn et al.,
2012 p. 1). The purpose of this campaign was to estimate the health impact and "potential costeffectiveness" of implementing such a program in the region (Kahn et al., 2012, p. 1). The
number of averted deaths and disability-adjusted life years (DALYs) were estimated from
published epidemiological data, which provided baseline statistics on illness mortality and
morbidity in the region. The efficacy of the program interventions in Western Province was
estimated using previously published community trials of the campaign's implementation. The
estimated savings in health care costs from averted illnesses were also recorded through costeffectiveness analysis (Kahn et al., 2012).
The model estimated that the integrated prevention campaign prevents 16.3 deaths per
1,000 individuals (Kahn et al., 2012). The prevention campaign also estimated the aversion of
442 DALYs per 1,000 of the participants, which are based on reduction in life years due to
illness mortality and morbidity. Through disease prevention, the campaign was said to be able to
produce savings in medical treatment costs of up to $85,113 per 1,000 individuals (Kahn et al.,
2012).

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Although this was a cost effectiveness analysis and the "health impacts and averted care
costs" of the campaign are "modeled, rather than measured directly," a community integrated
prevention campaign in Kenya does appear to be economically beneficial for malaria control,
HIV testing, and diarrhea control (Kahn et al., 2012, p. 7).
Hightower et al. (2010) conducted a study to determine if and how ITNs were being used
to decrease the occurrence of malaria in Kenya. Three million ITNs were distributed to
households throughout multiple provinces in Kenya. Of those that received ITNs, 2,100
households were randomly selected to take part in a survey that assessed the household, the
number of ITNs in the house, the number of ITNs that were being used, and which household
member slept under the ITNs. Other assessment questions included those regarding general
knowledge of malaria, awareness of media messages related to the campaign for malaria
treatment, and the socio-economic status of the household. As a result of this campaign, there
was a 50% increase in ITN ownership among the studied population. When specifically looking
at the target population, 74.4% of all households with children, aged 0-59 months, now owned
ITNs. The study also revealed that 95% of all the ITNs that were distributed were now being
retained within homes. In regards to the survey that was conducted post-ITN distribution, it was
concluded that there was a need for an increase in education and behavior changes to ensure
proper usage of the ITNs (Hightower et al., 2010).
Malaria is a dominant universal cause of "preventable morbidity and mortality, especially
in sub-Saharan Africa, despite recent advancements in treatment and prevention technologies"
(Dye et al., 2010, p. 1). However, increased utilization and effective maintenance of long-lasting
insecticide-treated nets (LLINs) could profoundly decrease the incidence of the infectious
disease in endemically stricken regions. Studies have shown that competent use of LLINs
depends on whether or not individuals are properly educated about the disease process of

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Malaria. Dye et al. (2010) underwent a study that assessed individual "malaria beliefs, attitudes,
and practices towards LLINs during a large-scale integrated prevention campaign (IPC) in rural
Kenya (p. 1).
Qualitative interviews revealed that most participants believed that mosquitoes caused the
disease; however, about half of those respondents also believed in a false additional cause to
malaria, such as cold weather or bad food (Dye et al., 2010). General attitudes toward LLINs
were positive and most community members were convinced that the LLINs would be
beneficial. Dye et al. (2010) concluded that "with improved understanding and clarification of
the causes of malaria, it is feasible that LLIN use can be sustained, offering beneficial
community-wide protection against malaria (p. 1).
Goals and Objectives
The main goal of the ITN maintenance program is that, within one year from its
initiation, the percentage of individuals in Kenyan communities who demonstrate proper use and
maintenance of their ITNs will increase to at least 80%. Subsequently, we hope to achieve the
long-term goal of decreasing incidence of malaria in these communities to below 10%. A
program objective that supports this goal includes increasing the percentage of high-risk
individuals (pregnant women and children under five years of age) that sleep under ITNs every
night in at least 80% of targeted communities. Another program objective is that communities
that have received ITNs will know how to use and maintain them correctly to ensure their
effectiveness after program educational sessions are conducted. Educational sessions will be
conducted by volunteers in the targeted communities to educate about appropriate use and
maintenance of ITNs.
To measure the effectiveness of these objectives, both baseline and post-program surveys
of communities in which the program is implemented will be conducted. This is done by

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measuring the percentage of Kenyan communities that maintain their ITNs appropriately,
measuring the percentage of high-risk individuals in targeted communities sleeping under ITNs,
and measuring recorded incidences of malaria in these communities. The malaria incidence rate
will exhibit a possible reduction of the diseases occurrence after ITN maintenance program
implementation, and will also demonstrate if there is any correlation between a decreased
incidence rate and an increased number of high-risk individuals utilizing the ITNs. Strategies to
achieve these objectives, and the overall goal, will include the following: providing various
malarial educational sessions, which will be conducted by a team of volunteers in Kenyan
communities; equipping communities with information as to which high-risk populations should
have priority use of ITNs; educating the community on appropriate ITN use and maintenance;
supplying targeted Kenyan communities with ITN maintenance supplies to allow individuals to
take charge of their own protection; and monitoring program efficacy by surveying documented
malarial incidences and the maintenance of household ITNs on a monthly basis.
A logic model, which can be viewed in the Appendices, has been written to decrease
incidence of malarial cases in Kenyan communities that have previously received ITNs, and
includes an outcome indicator of 80% of the target population reporting utilizing and maintaining
ITNs correctly. The aims are to provide knowledge on proper ITN use, proper ITN maintenance,
and information as to which individuals are at high-risk for contracting malaria and need to be
utilizing the ITNs. This knowledge will be provided through educational sessions conducted in
targeted Kenyan communities, utilizing a train-the-trainer model of education. After initial
education sessions, volunteers will evaluate progress and program effectiveness monthly, while
providing refresher courses on an as-needed basis. Tools and materials will also be distributed to
aid and encourage proper maintenance of ITNs.

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Technical Approach
Skilled administrative and field staff is needed in order to ensure that this project runs
efficiently and successfully (Okiro et al., 2011). The project team will work closely with the
CDC and the WHO in order to ensure the safety and health promotion of individuals in Kenya,
Africa. It would be ideal for this program to secure an administrative building in Nairobi, Kenya
to allow staff to headquarter and collaborate there. A potential barrier to this proposed
partnership with the CDC and WHO would be the possibility of these two organizations refusing
to support the project teams humanitarian efforts. In order to overcome this barrier, the team
plans to provide a detailed explanation of its mission, goals, outcomes, and planned successes, so
that these organizations are convinced to support and collaborate with the project team (Okiro et
al., 2011).
An educator with adept knowledge of malaria will be hired (Okech et al., 2008). This
individual will educate the project team, volunteers, and employees everything they need to
know about the infectious disease such as infection rates, disease process, transmission,
treatment, prevention, and its pathophysiology. The team, in turn, will be dispersed into selected
regions and communities to educate indigenous citizens. The objective of this is that the target
population will become more receptive to the implementation and maintenance of ITN
retreatment and repair facilities that will be placed within their communities (Okech et al., 2008).
Volunteers and employees need to be interviewed, selected, trained, oriented, and placed.
They will be recruited from the United States and Africa, and will be selected on a one-to-one
interview basis. During the interviews, they will be asked questions about their background and
experience, so that the project team can capitalize and maximize the usage of the recruited
individuals talents. Having a dynamic and diverse team will allow many different ideas and
viewpoints that can be conveyed into the project and assist in covering all the subjects of

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importance. Having a well-rounded project team is beneficial to the attainment of proposed

outcomes, especially when some members are experts in malaria treatment and prevention.
In an attempt to minimize overhead costs and make the most of resources, the project
team plans on establishing partnerships with supporting companies. These companies include,
but are not limited to, insecticide production manufacturers, net suppliers, car retailers, and
stores that sell sewing supplies for net repairs. Mailers, interviews, meetings, luncheons, and
one-on-one sales pitches from volunteers and employees of the project team will solicit these
partnerships. A barrier to this goal will be that the project team is unable to secure the needed
resources. This barrier will be overcome by having possible backup suppliers, so that they can
approach Plan B, if Plan A falls through or proves to be unsuccessful.
A team will be assembled to research and examine for prospective communities that have
already received ITNs and are in need of instruction on how to prolong the life of the nets. It is
important to assess these communities in Kenya for the existence and prevalence of current
malarial cases. This should be done so that evaluations can be conducted in the postadministration stages to check for the effectiveness of the ITNs and to measure the success of the
programs goals and objectives. If the project team is unable to locate the communities, they will
utilize local resources and health officials to help map the locations of the communities already
employing the use of ITNs.
Volunteers and employees will need to be assigned to different communities within each
targeted region. They will distribute, monitor, and maintain ITNs by educating local members of
the chosen communities on how to effectively run the program independently. To accomplish
this, a Material Shipping & Distribution hub will need to be established in Kenya. Barriers will
arise if this task is not completed, for project volunteers and employees will be unable to
effectively distribute new ITNs.

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In order to ensure proper ITN maintenance, ITN Maintenance & Repair Programs will
need to be set up in each community that is associated with the project. These programs will be
run/monitored by a different female every month. Each female volunteer will be recruited using
the above-mentioned interview techniques, and will be trained to re-dip previously-used nets into
water/insecticide mixtures, repair broken nets, and distribute new nets if necessary. These
volunteers will also be in charge of documenting new cases of malaria within the community of
which they are working in. These different locations will be monitored and assessed monthly to
make sure that program goals and objectives are being met, and that previously-assessed malaria
rates are decreasing.
A huge project undertaking will be that of teaching the community members to use, dip,
and repair the ITNs (Mutuku et al., 2013). This task will be completed by volunteers and
employees of the project team, and will be done to selected members of the chosen communities.
These members will have demonstrations, return demonstrations, and an opportunity to ask all of
their questions. The goal is that these facilities will be self-serving and locally available to the
community citizens with minimal intervention by the project team. Translators and previouslychosen community members will be present, so that the teaching and transitions are as smooth as
they can be. If any problems arise, they will be taken up the chain of command within the
project team and be addressed by the administrative staff. The administrative staff will cooperate
and collaborate with the field staff to ensure these barriers are overcome with little hindrance to
the overall quality of the operation (Mutuku et al., 2013).
Monitoring and Evaluation Plan
When designing a public health program, it is necessary to monitor and evaluate how the
program is working. Quantitative and qualitative data will be collected to monitor and evaluate
whether or not communities within Kenya are effectively using and maintaining ITNs.

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Quantitative data collected includes monitoring malaria rates as an impact method, outcome
indicators to determine changes in use, and process tracking to monitor interventions.
Qualitative data will be collected through survey questionnaires and by conducting interviews
with local community members.
An impact method of evaluating the effectiveness of the plan is to monitor malaria rates.
Clinical diagnosis of malaria is based on the patient's symptoms and on physical findings at
examination (CDC, 2010b). However, malaria can be confirmed using a variety of laboratory
tests. The CDC currently lists Kenya as having malaria everywhere except for the highly
urbanized areas of Nairobi. Using hospital data, the CDC can monitor rates of malaria over an
extended period of time to evaluate the long-term impact of the program (CDC, 2010b).
Along with impact indicators, outcome indicators are important in monitoring and
evaluating the program. Roll Back Malaria (RBM, n.d.), a program already in place, has
developed policies towards malaria control and the monitoring of the efficacy of their
interventions. They have developed the Malaria Indicator Survey (MIS), which provides various
templates and models, as well as data analysis and reporting. These include household
questionnaires, interviewer manuals, sampling guidelines, and brochures. Household
questionnaires contain questions regarding demographic information, complete household
listings, records of selected household assets, and the recommended met roster for recording ITN
possession and use (RBM, n.d.). To ensure that the program is effective, members of the
community would initially complete the surveys and questionnaires, and periodically complete
them throughout the first year of the program.
Household survey indicators are a standard outcome indicator that can be used in
quantitatively evaluating the plan. This can measure the proportion of households with at least
one ITN or at least one ITN for every two people (RBM, n.d.). It can determine the proportion

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of the population, the proportion of children under five years old, the proportion of pregnant
women who slept under an ITN the previous night, and the proportion of children less than five
years of age who slept under an ITN during the previous night. It also examines the proportion
of existing ITNs used the previous night. In addition, the proportion of ITNs sprayed by the
indoor residual sprays (IRS) in the past twelve months is determined (RBM, n.d.). Using
outcome indicators can be an effective tool in directly measuring community compliance of the
program and, therefore, their perception of malaria. Outcome indicators will also be assessed
initially and periodically throughout the first year in order to evaluate the effectiveness of the
program.
While monitoring malaria rates is an impact indicator and monitoring the use of ITNs is
an outcome indicator, process indicators are necessary to monitor how well the program is
working. Measuring the process of the plan is indicative of its effectiveness. The percentage of
training sessions providing information about the purpose of ITNs and the method of fixing them
with a level of attendance above 10 people will be tracked. At the time of each teaching session,
surveys will be done by participants to evaluate their perceptions of the program. By receiving
feedback on community members perceptions of what ITNs are used for and ratings of how
useful and comfortable they feel about them, the program can be qualitatively evaluated. To
evaluate the effectiveness of the demonstrations regarding what theyve learned at the end of
each teaching session, members will be asked to restate and demonstrate what they have learned.
Through evaluating each individual intervention, the overall program can be better evaluated.
Community volunteers and program employees will be responsible for monitoring and
evaluating responses. Community volunteers will be educated by program developers regarding
how to accurately conduct the surveys and questionnaires, and will be responsible for retrieving
data from the initial and periodical surveys. As stated, members of the community will complete

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the surveys and questionnaires periodically throughout the first year of the program. The data
will be analyzed monthly for the first quarter of the year and each consecutive quarter for the
remaining year. Once the gathering of data has been achieved, a meeting will take place to
discuss the effectiveness of the program. The meeting will consist of program developers,
community volunteers, community members, stakeholders, and partners. By obtaining and
sharing data, the program team can collectively discuss results and make necessary changes to
make the program as effective as possible.
Using a variety of indicators is essential in monitoring and evaluating a plan. By
observing for any impact through malaria rates, the outcome through percentage of ITN use, and
process indication through the amount of teaching sessions, it can be known how effective the
program being implemented is working.
Appendix A

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Implications for combating malaria from the literature reviews shows that the prevalent
incidences of malaria and lack of knowledge on ITN usage identifies a need to address and teach
affected Kenyan communities on proper use and maintenance of ITNs to reduce the number of
malaria cases. In the long run, our program proposal ultimately seeks to reduce the incidences of
malaria cases in targeted population by increasing the percentage of insecticide treated net usage
and proper maintenance. Thus, the purpose of our program is to implement appropriate
educational sessions on proper ITN maintenance that will expand the lifespan of the nets and
protect the Kenyan populations that are highly affected by malaria.

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