Transmitted by mosquitoes, malaria is an infectious disease that can cause high fever, profuse sweating, chills, vomiting, and convulsions. Almost half of the world’s population is at risk of contracting malaria, and there is no vaccine available. In 2015, there were more than 200 million cases of malaria worldwide, and young children and pregnant women are particularly vulnerable to malaria. The disease is the leading cause of death in the Democratic Republic of the Congo (DRC), accounting for approximately 1 out of 5 deaths of children younger than five.
Malaria can be treated using Artemisinin-based Combination Therapy (ACT), which requires patients to take pills at the same time every day for three days. But in order to prevent disease-causing mosquito bites in the first place, insecticide-treated bed nets are an effective barrier to protect people. While these prevention and control measures have led to a decrease in global malaria mortality rates in recent years, they are not always fully and adequately implemented. The MSF field team in Bili believed that a better understanding of these barriers and treatment would improve the reach and quality of the project.
These studies focused on study sites in Bili, a very remote area in the northwestern part of the DRC. How did you travel to this region?
The DRC can be particularly difficult to access, and the four study sites – Baya, Bili, Gbagayaembo, and Pandu – are located close to the border with the Central African Republic (CAR), a region where conflicts have caused people to be displaced over the border into the DRC. In 2016, MSF opened a project in Bili to respond to the medical needs of refugees from CAR. The following year, the project’s focus shifted to malaria treatment for children under 5, who are especially susceptible to infection and illness, which may lead to death.
Getting to Bili required taking a UN Humanitarian Air Services (UNHAS) flight, followed by a bumpy journey by road of around 120 kilometers. Due to road conditions and the remote nature of the region, the drive alone took us seven hours. To add to this isolation, there are only a few radio stations and limited telecommunication networks in this area, restricting communication.
Along with a full field research team and another qualitative LuxOR researcher, Emilie Venables, you were in the DRC to conduct qualitative research on adherence to malaria treatment and prevention measures. There were a lot of Bili project resources dedicated to better understanding why some people interrupt or stop taking their medication. Can you tell us more about your activities during these studies?
In qualitative research, interviews are essential. While in Bili and the other study sites, we interviewed “mamans” (mothers or caregivers), village chiefs, and healthcare workers to explore the reasons for adhering to or stopping ACT treatment for malaria. We also observed interactions between clinicians and patients, as well as how information on when and how to take medication was shared. We conducted additional interviews to determine people’s understanding and use of mosquito bed nets.
Your team has finished interviews and data collection, and two health promoters are continuing the studies. Are there already initial findings from these studies?
It turns out that malaria is a well-known disease in the region, and that many people have firsthand experience with the illness. As a result, people are very familiar with bed nets and ACT treatment, to the point where they even use the acronym with ease.
However, there is a poor understanding of how malaria is transmitted, and we found that a common misconception is that the disease is linked to coolness, or “fraîcheur,” in French. Not realizing that mosquitos cause malaria makes people less vigilant with protective measures, and many use bed nets that contain holes or are of poor quality as they cannot always access new ones.
We also found that there are often not enough bed nets available in people’s homes for all household members to be adequately protected. During interviews, we learned that as many as seven people sleep under a bed net designed for two people. Children, especially newborns, and guests are prioritized when there is not enough space for all family members to sleep under a bed net.
Treatment based on Artemisinin-based Combination Therapy (ACT) is an effective way to treat malaria in almost all settings. What are some of the challenges people in Bili face in taking ACT?
There are several challenges and at times confusion regarding ACT treatment, especially when children are infected. ACT pills need to be taken at the same time every day for three days to be effective. However, ACT tablets are large and bitter, so children may have difficulty swallowing the pills and may even vomit the tablets up. When this happens, it can be unclear when to take the following doses. And if caregivers, or “mamans,” do not return to the health structure for replacement tablets, children receive incomplete and insufficient treatment.
Moreover, the person who brings a sick child to a health structure for treatment could be a sibling or neighbor, and is not necessarily the person who will follow up with the child’s treatment and care. Therefore, the child’s primary caregiver may not receive directions on how to properly administer the medication when the child returns home.
What are the next steps to be taken to continue to decrease malaria cases in the DRC and improve treatment adherence for malaria in Bili?
One of our objectives was to identify ways to improve and encourage adherence to ACT and bed net usage. The distribution of bed nets is currently calculated based on household size, but should take into account both the size of the family as well as potential visitors. In addition, while there are plans for regular distributions by the Ministry of Health, these have been delayed. Distributing nets more frequently or verifying that they remain intact can help protect people from mosquito bites.
Many health professionals assume that a one-time explanation of how malaria medication works leads to a change in behavior among their patients. Yet explanations need to be given multiple times to ensure understanding of and adherence to treatment.
Another key recommendation of the study is that caregivers who had already administered ACT treatment to their children should be asked to share their experience with others. This approach is similar to one used in HIV programs, where “expert” patients share their experience with other patients. In this way, “experienced” caregivers could provide practical advice, such as crushing ACT tablets with water and sugar to mask the bitter taste and to ensure the child swallows the medicine.
We have now finished the interviews and data collection for all of the study sites, and our next steps involve transcribing and translating the data from Lingala to French, analyzing observations, writing up the findings, and sharing them with our team on the ground and partners, such as the local Ministry of Health. In addition, MSF continues to run health centers and clinics in Bili, providing free care for children under 5 and teaching communities how to prevent malaria, an essential measure in combating the disease in the DRC.