ufdcimages.uflib.ufl.edu€¦ · Web viewUnfortunately for the people of Haiti, 99% of malaria infections are caused by the most deadly species of malaria, Plasmodium falciparum

Running head: PRELIMINARY ANALYSIS OF MALARIA IN HAITI 1

Honors Project Thesis

A Preliminary Analysis on Bed Net Coverage and Perceptions of Malaria in Haiti

Catherine Solaun

University of Florida

PRELIMINARY ANALYSIS OF MALARIA IN HAITI 2

Introduction

Malaria is a parasitic disease, transmitted by anopheline mosquitoes, that invades

red blood cells. Cyclical fever, fatigue, chills, and severe anemia usually characterize this

infection, with the presentation varying by individual genetic factors, the species of

malaria parasite, and the overall health status of the exposed individual. If patients do not

receive appropriate treatment, they may develop severe complications, like cerebral

malaria, and may eventually die. The World Health Organization (WHO) estimates that

207 million cases of malaria occurred in 2012, with the Africa Region accounting for

80% of malaria cases and 90% of malaria deaths worldwide. Malaria is responsible for an

estimated 627,000 deaths annually, of which a majority occur in African children under

five years of age. It remains one of the top five causes of infectious disease mortality,

ranked behind respiratory infections, HIV/AIDS, and diarrheal diseases (Malaria Fact

Sheet, 2013). According to the World Malaria Report 2013 there were 25,423 confirmed

cases of malaria in Haiti in 2012, however accurate surveillance in this country can be

questionable, with Pan American Health Organization (PAHO) estimating as many as

200,000 cases occurring annually. Unfortunately for the people of Haiti, 99% of malaria

infections are caused by the most deadly species of malaria, Plasmodium falciparum. In

order to better prevent and treat malaria in this population it is necessary to gather

baseline data about the epidemiology and prevention strategies used to combat this

disease in Haiti, with the aim of guiding policy.

There are several methods for treatment and prevention of malaria in developing

countries, such as bed nets, insecticide use, window screen coverage, indoor residual


spraying and antimalarial medications. Bed nets are used globally as a common way to

prevent malaria because they are easily distributed and create a tangible layer of

protection from mosquitoes. The United Nations and the Haitian Ministry of Health

distributed three million bed nets in Haiti; however, there is limited data about whether or

not the bed nets are actually being used properly in Haiti (World Malaria Report, 2013).

Therefore there are many questions on the participant survey used in this research project

that are aimed at gathering information about the distribution of the bed nets and if, how,

and when they are being used. The level of education and awareness of Haitians in regard

to malaria is limited and therefore the surveys also assess the participants’ perceptions of

malaria and the prevalence of malaria in their community. Bed nets are an important

malaria prevention measure because they provide a physical barrier between the infected

mosquito and the person. Many other studies consider this to be an important exposure

risk factor and in order to attain an accurate measure of malaria exposure risk this

variable is crucial. As part of a larger malaria study, the purpose of this honors thesis is

to examine the baseline bed net usage rates and perceptions of malaria in Haiti by using

data from questionnaires collected in the Ouest and Sud-Est departments of Haiti.

Methods

This study was conducted in the Ouest and Sud-Est departments of Haiti between

February and May of 2013. In the Ouest department, household members of children

from the Christianville School in Gresier were surveyed. In the Sud-Est department,

heads of households from the rural village of Chabin, and in the city of Jacmel, legal

guardians of participants attending the Leogane Clinic and Hossana Baptist School were


surveyed. All surveys were administered in Creole, and translated back to English at the

Emerging Pathogens Institute. A copy of the survey instrument is found in Appendix A.

The purpose of the survey was to gather more information about bed nets usage,

perceptions of malaria in Haiti, insecticide use, and window screen coverage, for the

purpose of examining exposure risks. This study is considered to be qualitative due to the

participants’ individual responses to the survey. A total of 376 household surveys were

collected from hospitals, clinics, and schools in Gressier, Chabin, and Jacmel, Haiti, as

part of a larger malaria study in the Ouest and Sud-Est departments of Haiti. Gressier is a

semi-urban community, 10 km outside of Port-au-Prince, while Chabin is a poor

mountain community that was reached by using a mobile clinic. The city of Jacmel has a

relatively high socioeconomic status compared to other areas in Haiti, with children often

commuting from rural regions surrounding the city to attend school. Researchers from the

University of Florida, along with collaborators in Haiti, traveled to each location and

consented participants before enrolling them in this study, as per IRB requirements.

Once surveys were collected and de-identified, their answers were put into Excel format

by the author and the research team.

The surveys contained questions pertaining to risk factors for malaria, which

included bed nets, insecticide use, and window screen coverage. The risk factors also

included access to care, time of sleep, and housing construction materials. If the

participants lived farther away from care then there is an increased risk for not attaining

appropriate preventative and treatment measures for malaria. The time of sleep for

participants is significant because malaria-carrying mosquitos in Haiti generally have the


highest rate of biting from 8-10pm. Therefore, if participants go to sleep after or during

this time, they are at an increased risk for being bitten. The participants’ housing

conditions also contributed to the level of risk for malaria because if they had many

windows or doors without screens, are geographically nearby standing water, and lack

indoor insecticide use this can all increase the participants’ vulnerability to contract

malaria. The second section of questions included community perceptions and knowledge

of malaria. Examples of these questions included asking the participants how they think

malaria is contracted and rating the “problem of malaria” for their family on a scale from

one to five. These questions aimed to determine the level of understanding and

perceptions Haitians have regarding this disease.

The coded responses were entered into an excel sheet which helped organize it for

data analysis calculations. Data were cleaned to remove outliers and incomplete

responses. Several simple analyses were computed and focused on frequency, summary

statistics on the number of bed nets per household, and total number of people living in

each house, which were all calculated by site of enrollment.

Results

The total number of Households surveyed was 376, with 135 in Christianville,

112 in Jacmel, and 128 in Chabin. The participant’s ages ranged from 12 to 87 years old,

with an average age of 24. There were 232 females and 117 males. Seven participants

were positive for the malaria spot test.

Malaria risk factors were assessed by sampling location. The average household

bed-net coverage for all three locations was 31%. However, major variation was


observed by sampling location, with the Gressier school having 48.1% coverage, Jacmel

(school) having 37.7%, Jacmel (clinic) having 33% and the rural community of Chabin

having 17.1%. The average window screen coverage for all three locations was 74.4%.

However, some variation was observed by sampling location, with the Gressier school

having 77.2% coverage, Jacmel (school) having 83.4%, Jacmel (clinic) having 74.1%,

and Chabin had 80.8%.

Lastly the patients’ knowledge and perception of malaria were assessed. On

average, 80.3% knew what malaria was. Households from the Gressier school had the

highest score of 85.9% knowing what malaria was, with only 70.7% of households from

the Jacmel school knowing what malaria was. Another finding pertained to the survey

question about the perceptions of risk and impact that malaria has on the family and

community. In all three locations the community perception was higher than the family

perception, which may indicate participants’ tendency to distance themselves from the

public health issue at hand.

Discussion

The communities that are the least equipped to prevent and treat malaria are often

at the highest risk of developing the disease. Bed nets have historically proven to be an

effective malaria prevention strategy, and this preliminary data coincides with this

finding. The sampling site in Gressier had significantly higher bed net coverage (48.2%)

than Chabin (17.1%), the Jacmel school (37.7%), and the Jacmel clinic (33%). Gressier

also had zero positive malaria spot tests, whereas Chabin and the Jacmel clinic each had

three, however this may be more of a result of sampling method than actual malaria


prevented. Increasing bed net coverage in Haiti represents a viable strategy to reduce the

transmission of malaria and other vector borne diseases. Other malaria risk factor data

gathered in these surveys included access to care, time of sleep, standing water, number

of animals owned, housing material, occupation, and education, all of which should be

included in future analysis. More information on the anopheles albimanus mosquito is

required, as mosquito feeding preferences, resting behaviors, and vector competency all

have an impact on malaria transmission. All communities were within 10% of the

average knowledge base for what malaria is, with the Jacmel school being the lowest at

70.7%. The findings for the perception of malaria indicated that the participants felt that

malaria is more of a problem for their community than their family, which can be telling

of how malaria is viewed in Haiti.

Overall this information is important because it provides baseline data on malaria

exposure statistics, which is often not captured in other national strategies. Further

analysis of patient serum matched with the survey results will provide rich data on the

extent these factors influence transmission dynamics in Haiti.

Thoughts and Experiences

The author joined this research project after the participants had been consented

and surveyed. The author’s preceptors were extremely accommodating and helpful in

narrowing down the research topic, and also offered essential guidance throughout the

process. They were very patient and constantly encouraged the author to take part in the

different features of the research process. The main function of the author in this project

was inputting data into excel spreadsheets, gathering literature on malaria in Haiti, and


generating summary statistics based on survey findings. Data was entered based on the

survey answer choice that was selected in the following manner; if someone marked “X”

next to “Less than High School” then “1” would be put into the data sheet. If the

participant marked “High School Equivalent” then that answer would be put in as “2”,

and if they responded “University” that would code as “3” and so on (See Appendix A

for the participant survey).

The preceptor taught the author how to code and input the survey data in an

efficient manner (Microsoft Office, 2010). Working on this project taught the author

much about the importance of cleaning and managing data. Inputting the data in this

format allowed for statistical analysis and programs to be run in a much more convenient

way and improved the efficiency of producing findings and conclusions, which would

allow the preceptor to merge this data set with his research examining rates of malaria

exposure in blood samples collected from Haiti. Since the preceptor was also inputting

the data into the same spreadsheet he created a method to code the data in order promote

concordance of the interpretation of the participant responses. However there were many

unique and somewhat indeterminate answers often hand written in Creole, therefore the

preceptor and author had to work together to decide how to properly decipher responses

for these ambiguous situations.

Problems & Solutions

There were several issues that arose during this study. However by collaborating

with the author, preceptor and other healthcare leaders the issues were overcome. One of

the issues in the beginning of this study included scheduling issues; since the members of


the research team were very busy it was difficult to find good times to meet. Another

concern was the number of surveys collected from each site. If the number was too small

then the results may not accurately represent the populations of interest. The main barrier

to adding participants to the study was the cost and inconvenience of traveling to Haiti.

However, the preceptor was able to contract survey collection out to his Haitian

collaborators in order to gain additional household surveys from previously enrolled

participants.

The surveys were fairly straightforward and written with appropriate information

and reading level for the participants, however some people interpreted the questions and

answers in unanticipated and unintended ways. For example some people marked two

answers for a question that was intended to have one answer. The language barrier

became a slight issue as well. Some questions, once translated to Haitian Creole, became

very technical and were lost in translation. In order to resolve this issue the preceptor and

author communicated frequently to adjust the code as needed and assist in the

interpretation of the participant answers.

One of the most important things that the author learned throughout this research

was the necessity for teamwork and collaboration. At times when the research team was

stumped on interpreting a participant answer or a language translation they would confer

with other colleagues who brought different skills, such as fluency in French or Creole.

The collaboration of the Haitian-based consenter also illustrates the importance of

exploring other opportunities to improve the efficacy of data collection. This experience

has enhanced the author’s understanding of academic research, the methods to


disseminate results, and the importance of scientific writing. Throughout this project the

author has also learned the importance of balance between academics, social life, and

research. Although challenging, the author has realized that this balance is very

important.

Recommendations

There are several recommendations that the author would have for students to

forestall problems in this research project. Firstly, she would advise them to make a

schedule with a timeframe of short-term goals for the research project, because the author

feels that if she did not write “research time” into her schedule then she would get

distracted by other schoolwork and extracurricular activities. A timeframe of short-term

goals would be beneficial because the independent-based aspect of research can be

somewhat overwhelming. Therefore a timeframe can help improve the organization and

efficiency of developing an honors thesis proposal and executing the project in a timely

fashion. This research project involves a large number of students and researchers;

therefore a concrete schedule might improve the communication and teamwork overall.

The type of learning that the author experienced throughout her research has been

more independent when compared to traditional undergraduate education, forcing her to

develop unique critical thinking skills and become more familiar with using scientific

databases and finding sources pertaining to nursing-related issues. In conclusion the

author found this project to be very enlightening to both the research process and to the

malaria epidemic in Haiti.


References

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Appendix A



Documents

ufdcimages.uflib.ufl.edu€¦ · Web viewUnfortunately for the people of Haiti, 99% of malaria infections are caused by the most deadly species of malaria, Plasmodium falciparum