Factors impeding the acceptability and use of malaria preventive measures: implications for malaria elimination in eastern Rwanda.

BACKGROUND: Long-lasting insecticidal nets (LLIN), indoor residual spraying (IRS) and malaria case treatment with artemisinin-based combination therapy (ACT) have been proven to significantly reduce malaria, but may not necessarily lead to malaria elimination. This study explored factors hindering the acceptability and use of available malaria preventive measures to better inform area specific strategies that can lead to malaria elimination. METHODS: Nine focus group discussions (FGD) covering a cross-section of 81 lay community members and local leaders were conducted in Ruhuha, Southern Eastern Rwanda in December 2013 to determine: community perceptions on malaria disease, acceptability of LLIN and IRS, health care-seeking behaviours and other malaria elimination strategies deployed at household and environmental levels. Discussions were recorded in Kinyarwanda, transcribed into English and coded using Nvivo 10 software. RESULTS: Participants ranked malaria as the top among five common diseases in the Ruhuha sector. Participants expressed comprehensive knowledge and understanding of malaria transmission and symptoms. The concept of malaria elimination was acknowledged, but challenges were reported. Sleeping under a bed net was negatively affected by increase of bedbugs (and the associated irritability) as well as discomfortable warmness particularly during the dry season. These two factors were reported as common hindrances of the use of LLIN. Also, widespread use of LLIN in constructing chicken pens or as fences around vegetable gardens was reported. Participants also reported that IRS appeared to lead to an increase in number of mosquitoes and other household bugs rather than kill them. Prompt health centre utilization among participants with presumed malaria was reported to be common particularly among subscribers to the subsidized community-based health insurance (CBHI) scheme. In contrast, the lack of CBHI and/or perceptions that health centre visits were time consuming were common reasons for the use of over-the-counter medicines for malaria management. CONCLUSION: In this study, identification of behavioural determinants in relation to LLIN use, IRS acceptability and health care seeking is a critical step in the development of effective, targeted interventions aiming to further reduce malaria transmission and elimination in the area.

Local resource mobilization for malaria vector control among Rwandan rice farmers: a pilot study into the role of community ownership.

BACKGROUND: Evidence suggests a vicious cycle between rice cultivation and malaria control in Rwanda. Rice fields offer an attractive breeding ground for malaria vectors, which increases the disease burden in rice farming communities, and, consequently, reduces productivity in the rice sector. Community-based larval source management in rice fields is propagated as a sustainable solution to break this cycle. A sense of agency and ownership of malaria control interventions, as well as the mobilization of resources at the local level, are often considered preconditions for success. However, an evidence gap exists regarding the interaction between the agentive and financial dimension of local sustainability. METHODS: We conduct a larviciding pilot involving three groups; one group where rice farmers sprayed their fields under expert supervision, one group where rice farmers organised the larviciding campaign themselves, and a (non-sprayed) control group. We test whether the difference in agency between the intervention groups affects farmers' willingness-to-pay for a larviciding campaign. Willingness-to-pay is elicited in a contingent valuation exercise, more specifically a bidding game, and is assessed both before and after the pilot (n = 288). Difference-in-difference estimates are computed, using a propensity score matching technique. Supplementary data were collected in a survey and two focus group discussions for triangulation. RESULTS: The high-agency (self-organised) group significantly outperforms the low-agency (expert-supervised) group in terms of maintaining its willingness to contribute financially. However, higher willingness-to-pay in the high-agency group does not appear to be driven by a stronger sense of ownership per se. The supplementary data indicate high levels of ownership in both treatment groups compared to the control group. A tentative explanation lies in diverging perceptions concerning the effectiveness of the pilot. CONCLUSIONS: The study supports the idea that community-led organization of larval source management can prove instrumental in mobilizing finance for malaria control in low-income settings where rice production interferes with the fight against malaria. However, the causality is complex. Feelings of ownership do not appear the main driver of willingness-to-pay, at least not directly, which opens up the possibility of initiating community-driven malaria control interventions that promote the agentive and financial dimension of local sustainability simultaneously.

Willingness to Contribute to Bio-Larviciding in the Fight against Malaria: A Contingent Valuation Study among Rice Farmers in Rwanda.

There is broad consensus that successful and sustained larval source management (LSM) interventions, including bio-larviciding campaigns, require embeddedness in local community institutions. Ideally, these community structures should also be capable of mobilizing local resources to (co-)finance interventions. To date, farmer cooperatives, especially cooperatives of rice growers whose economic activity facilitates mosquito breeding, have remained under the radar in designing community-based bio-larviciding campaigns. This study explores the potential of rice farmer cooperatives in Bugesera district, Rwanda, to take up the aforementioned roles. To this purpose, we surveyed 320 randomly selected rice farmers who belonged to one of four rice cooperatives in the area and elicited their willingness-to-pay (WTP) for application of Bti, a popular bio-larvicide, in their rice paddies. Results from a (non-incentivized) bidding game procedure, which tested two alternative contribution schemes showed that financial contributions would be significantly different from zero and sufficient to carry a co-financing share of 15-25 per cent. A strong heterogeneity in mean WTP is revealed across cooperatives, in addition to variation among individual farmers, which needs to be anticipated when engaging farmer cooperatives in LSM.

A perverse 'net' effect? Health insurance and ex-ante moral hazard in Ghana.

Incentive problems in insurance markets are well-established in economic theory. One of these incentive problems is related to reduced prevention efforts following insurance coverage (ex-ante moral hazard). This prediction is yet to be tested empirically with regard to health insurance, as the health domain is often considered relatively immune to perverse incentives, despite its validation in other insurance markets that entail adverse shocks. This paper tests for the presence of ex-ante moral hazard with reference to malaria prevention in Ghana. We investigate whether enrollment in the country's National Health Insurance Scheme (NHIS) negatively affects ownership and use of insecticide-treated bed nets (ITNs). We use a panel of 400 households in the Brong Ahafo region for this purpose and employ a propensity-adjusted household fixed effects model. Our results suggest that ex-ante moral hazard is present, especially when the level of effort and cost required for prevention is high. Implications of perverse incentive effects for the NHIS are briefly outlined.

Subjective Well-being in Rural India: The Curse of Conspicuous Consumption.

Using data on 697 individuals from 375 rural low income households in India, we test expectations on the effects of relative income and conspicuous consumption on subjective well-being. The results of the multi-level regression analyses show that individuals who spent more on conspicuous consumption report lower levels of subjective well-being. Surprisingly an individual's relative income position does not affect feelings of well-being. Motivated by positional concerns, people do not passively accept their relative rank but instead consume conspicuous goods to keep up with the Joneses. Conspicuous consumption always comes at the account of the consumption of basic needs. Our analyses point at a positional treadmill effect of the consumption of status goods.

The 'Downside' of Women Empowerment in India: An Experimental Inquiry into the Role of Expectations.

The paper reports on a field experiment conducted among poor women organized in self-help groups in the north-east of India. The experiment tests in a simple game whether overly optimistic expectations with respect to the benefits of exercising agency reduces one's appreciation of remaining with agency in the future. If so, unrealistic expectations may trigger behaviour that jeopardizes empowerment processes. It is hypothesized that negative emotions, such as disappointment, bring about such risks. We find that overstretched expectations may indeed work against empowerment if the gap between achieved and expected outcomes following increased agency is sufficiently wide. However, modest expectation gaps have the opposite effect and tend to promote attitudes conducive to empowerment. A tentative explanation for this result is offered by combining insights from recent work on the role of aspirations.