Highlights
- Traditional control techniques, such as insecticide-treated nets (ITNs) and indoor residual sprays (IRS), are reaching their limits due to resistance and changes in mosquito behaviour.
- Those working to reduce malaria in endemic areas should consider locals' priorities, knowledge, and experiences.
- Housing improvement is an acceptable malaria prevention method, this is modest and affordable.
- Housing improvement, like other control strategies, should be reinforced with other interventions.
Background
Nearly every minute, a child under the age of five dies of malaria in Africa. In 2021, sub-Saharan Africa (SSA) was home to more than 90 percent of malaria's 247 million cases and 619,000 deaths. Several efforts have resulted in a significant reduction of malaria over the past three decades; vector control efforts, in conjunction with widely accessible and affordable diagnosis and treatment services, have resulted in a reduction of more than 90 percent of malaria deaths worldwide. Insecticide-based vector control methods such as insecticide-treated nets (ITNs) and indoor residual sprays (IRS) have contributed to more than 75 percent of these gains. However, these interventions are rapidly reaching their limit due to obstacles such as rising insecticide resistance, alterations in mosquito behaviour, and inadequate access to and applicability of preventive methods.
Community participation in finding alternative solutions
It is becoming more evident that the interventions currently available will not be sufficient to sustain the progress achieved, and that novel and alternative tools are required to supplement the current interventions. Malaria vaccine, larval source management (LSM), spatial repellents, mass drug administration with endectocides such as ivermectin, and mosquito modification technologies such as gene drives are among the alternative approaches that are garnering popularity worldwide. Adapting these strategies carefully, along with current methods, could lead to the effective control and probable eradication of malaria in Africa.
Still, for any of these strategies to be effective, it is essential to comprehend malaria transmission dynamics at more local levels and to avoid the currently utilized one-size-fits-all solutions. Understanding the perspectives and behaviours of communities living in endemic settings is just as important as devising new tools to combat this disease effectively. There is a growing awareness of the need to involve local communities in malaria-endemic areas in the development of alternative approaches for malaria control. If done effectively, this could result in significant advances in eradicating this lethal disease. Listening to the communities in endemic settings could also result in addressing the root causes of some of the obstacles that have caused delays in achieving malaria control and elimination objectives and avoiding solutions that target the surface-level obstacles.
Poverty, housing, and malaria
Malaria is frequently referred to as the disease of poverty; globally, malaria is endemic in some of the world's poorest countries, and locally, malaria is still prevalent in the poorest and frequently rural areas. Then, it makes sense that alleviating poverty could have direct effects on the reduction or possible eradication of malaria. However, poverty is complex, and addressing it may appear to be an impossible undertaking. But comprehending the relationship between poverty and the risk of malaria transmission could be a crucial step.
One of the most prevalent factors in areas where malaria is endemic is poor housing. According to studies, more than 80 percent of malaria transmission occurs indoors. Similarly, several studies have linked substandard housing to higher densities of malaria vectors, greater likelihood of malaria infections, and greater odds of more severe malaria episodes. Interestingly, housing improvement is one of the earliest reported malaria control interventions in the world, associated with the eradication of malaria in Europe and the United States in the nineteenth and twentieth centuries. These facts would seem to place housing enhancement at the forefront of malaria control efforts.
Perceptions of housing improvement as a control
In contrast to ‘simpler' insecticidal methods for eliminating mosquitoes, national and international malaria-spheres have not shown much enthusiasm for this approach. A study in Tanzania provided endemic community members with a list of alternative malaria control interventions. Community members were more aware and knowledgeable about the role of housing development in malaria prevention and preferred it, saying that it made the most sense to them. Malaria control leaders at the national level, such as research scientists, policymakers, and regulators, showed little support for this concept due to its perceived high need, high cost, unsustainable nature, and lack of rigorous scientific evidence of its effectiveness. It became apparent that there was a lack of clarity regarding what housing enhancement for malaria control entails, its scope, and associated costs.
Another study was then conducted to determine the actual magnitude of the need for this approach, and it was discovered that housing improvement needs for malaria control purposes were quite modest; the majority of the more than 1000 households surveyed required window improvements, the majority of which required the addition of insect-screens, and the repair of gaps on walls, doors, and roofs to prevent mosquito entry. Only roughly a fifth of the families visited required comprehensive reconstruction, and the majority of them were in the most remote and endemic areas. The cost evaluation for a typical house size alteration ranged from 32 USD for window screening to 5,000 USD for whole house construction. When the overall benefits of malaria prevention were considered, it became evident that the needed improvements were quite minor. Because this is a community-preferred solution, it would be in the best interests of malaria control efforts to reconsider prioritizing this approach, as it may not only result in targeting the diseases in ways informed by the experiences of the affected communities, but it will also delegate responsibility for targeting this disease to the communities, who are already making efforts, although at a much slower pace.
Way forward
Finally, there is growing recognition that malaria control initiatives should take into account the needs, experiences, and preferences of communities living in endemic areas. Housing improvements provides an opportunity for meaningful co-creation of solutions. The communities are already making attempts to malaria-proof their homes, but major assistance is still required to help accelerate their efforts. The assistance might take the form of finance to help households achieve their home improvement goals much faster, research to provide greater evidence on the effectiveness of various renovations, and collaboration to co-develop more inexpensive but successful house-improvement solutions.
It is crucial to highlight, however, that improving housing alone will not be adequate to effectively control or eliminate malaria; in fact, no single instrument or strategy will result in effective malaria control. It is still critical to improve the efficacy and coverage of current tools such as ITNs, diagnosis, and treatment, and to supplement them with alternative approaches that consider the needs and preferences of endemic communities.
Some policy recommendations
- Increase funding for housing improvement in malaria-endemic areas to accelerate the malaria-proofing of homes.
- Support research that demonstrates the efficacy of various housing improvements.
- Involve local communities in malaria-endemic areas in the formulation of alternative malaria control strategies.
- Work with community to co-create more affordable but effective house-improvement designs.
Author and affiliation:
1. Ifakara Health Institute
2. Consortium for Advanced Research Training in Africa (CARTA) Graduate.
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