This is the html version of the file http://www.amref.org/Resource%20Packs_malaria/4KidaneMorrow.pdf.
G o o g l e automatically generates html versions of documents as we crawl the web.

Google is neither affiliated with the authors of this page nor responsible for its content.
These search terms have been highlighted:  regional  health  ethiopia 
Page 1
For personal use only. Not to be reproduced without permission of The Lancet.
ARTICLES
550
THE LANCET • Vol 356 • August 12, 2000
Summary
Background No satisfactory strategy for reducing high child
mortality from malaria has yet been established in tropical
Africa. We compared the effect on under-5 mortality of
teaching mothers to promptly provide antimalarials to their
sick children at home, with the present community health
worker approach.
Methods Of 37 tabias (cluster of villages) in two districts
with hyperendemic to holoendemic malaria, tabias reported
to have the highest malaria morbidity were selected. A
census was done which included a maternity history to
determine under-5 mortality. Tabias (population 70 506)
were paired according to under-5 mortality rates. One tabia
from each pair was allocated by random number to an
intervention group and the other was allocated to the control
group. In the intervention tabias, mother coordinators were
trained to teach other local mothers to recognise symptoms
of malaria in their children and to promptly give chloroquine.
In both intervention and control tabias, all births and deaths
of under-5s were recorded monthly.
Findings From January to December 1997, 190 of 6383
(29·8 per 1000) children under-5 died in the intervention
tabias compared with 366 of 7294 (50·2 per 1000) in the
control tabias. Under-5 mortality was reduced by 40% in the
intervention localities (95% CI from 29·2–50·6; paired t test,
p<0·003). For every third child who died, a structured verbal
autopsy was undertaken to ascribe cause of mortality as
consistent with malaria or possible malaria, or not
consistent with malaria. Of the 190 verbal autopsies, 13
(19%) of 70 in the intervention tabias were consistent with
possible malaria compared with 68 (57%) of 120 in the
control tabias.
Interpretation A major reduction in under-5 mortality can be
achieved in holoendemic malaria areas through training
local mother coordinators to teach mothers to give under-5
children antimalarial drugs.
Lancet 2000; 356: 550–55
See Commentary page
Introduction
Falciparum malaria is a major cause of mortality in
children less than 5 years of age in Africa. No satisfactory
strategy for reducing the high child mortality has yet been
established for most of tropical Africa. Although several
studies have shown that insecticide-treated bednets can
reduce parasitaemia,
1,2
clinical attacks,
3
and mortality,
4,5
they have limited widespread use. There is as yet no
vaccine.
6
Treatment with antimalarial drugs has been the most
widely used approach in efforts to reduce the effect of
malaria in Africa.
7,8
However, treatment provided
through health centres and health posts has been of little
help in reducing infant and deaths in young children
because severe falciparum malaria in these children
strikes so rapidly that mothers are not able to obtain
treatment in time.
9–11
Because of Ethiopia’s varied geography and ecology,
transmission of malaria is highly variable—ranging from
holoendemic in low-lying tropical-valley areas mainly in
the south, to hypoendemic and mesoendemic
transmission in the central and northern highland
plateaux. Tigray, too, is characterised by great variability
in altitude, ranging from more than 2400 m in the high
plateau areas to less than 1200 m in the low-lying rifts
and valleys that crisscross the plateau.
12
Civil war raged in Tigray from 1974 until 1991 when
the combined Tigrayan and Eritrean forces finally
overthrew the Mengistu regime and peace was restored to
the area. During the civil war the only health services
available in the Tigray area were community-based
primary health care initiated by the Tigray Peoples
Liberation Front (TPLF).
12–14
This programme was
strengthened after the end of the civil war, becoming a
community-based malaria control programme with
volunteers mainly recruited from among former TPLF
community health workers (CHW)
12
who received a
7 day malaria training course.
Being based on local community involvement, this
programme was generally well accepted. However,
limitations that were related to the sparse numbers of
CHWs, who were generally located only in main villages
and were virtually all men, became evident over time. An
assessment of the programme in 1994–95 found that the
main users were older children and adults and that very
few of the young and most vulnerable children were
actually being seen or treated for malaria. After careful
review and extensive discussions with community leaders
and local women, a completely new approach was
designed to overcome these limitations and meet the
needs of the under-served rural women and their
families. The new approach was based on the selection
and training of mother coordinators to teach all mothers
to recognise possible malaria and give chloroquine to
their young children. To assess its effectiveness, we
decided to do a randomised trial of this new approach.
The objective of the trial was to determine the effect on
Teaching mothers to provide home treatment of malaria in Tigray,
Ethiopia: a randomised trial
Gebreyesus Kidane, Richard H Morrow
Department of International Health, School of Hygiene and Public
Health, John Hopkins University, 615 N Wolfe Street, Baltimore,
MD 21205, USA (G Kidane
BS
, R H Morrow
MD
)
Correspondence to: Dr R H Morrow
(e-mail: RMorrow@jsph.edu)
Page 2
For personal use only. Not to be reproduced without permission of The Lancet.
ARTICLES
THE LANCET • Vol 356 • August 12, 2000
551
under-5 mortality of teaching mothers to promptly
provide antimalarials to their sick children at home
compared with the present CHW facility-based
approach.
Patients and methods
Study population
The study was done in the Alamata and Raya Azebo
districts of the Tigray region in northerm Ethiopia
(figure 1) in 1996–98. Most of Tigray is high plateau,
and has little if any malaria transmission. However, in
these two districts in the southern part of Tigray much of
the population lives in lower-lying land at 1000–1250 m
in which there is seasonal hyperendemic malaria. The
rainfall in 1997, the year the intervention was in place,
was unusual because it was untimely and irregular, with
rain nearly every month rather than the heavy seasonal
rains in January to February and June to July. Normally
most malaria cases occur between September and
November. Chloroquine resistance has not been reported
from this area of Ethiopia.
The two districts consisted of 37 tabias (a cluster of
villages), each with a population of between 1000 and
3000. Within each tabia are three to five kushets
(villages). The 24 tabias with the highest morbidity rates
were selected based on the 1994 annual malaria
morbidity reports from the zonal office of the Tigray
Community-Based
Malaria
Control
Programme
(TCBMCP). Mapping was done in the 24 tabias in
June, 1996, as well as a household census including a
maternity history to calculate under-5 mortality. The
population was registered with a unique identification
number by name, locality, household number, age, sex,
and relation to head of household.
The 24 tabias were paired according to their under-5
childhood mortality rates estimated from the maternal
histories obtained in the June 1996 census. One tabia
from each of the 12 pairs was allocated by random
number to the intervention group and the other to the
control. Table 1 presents the pairing of the tabias;
figure 1 shows the geographical location of the pairs.
Procedure
Mother coordinators were selected in all tabias. By means
of the registration book, neighbour groups were formed
from every 20 neighbouring houses with children less
than 5 years in the intervention tabias, and similarly from
every 33 households in the control tabias. Originally, the
intention was to select from each of 20 households in the
control tabias as well, but when it became evident that
there was much less for mothers to do, the community
leaders recommended fewer mother coordinators in these
tabias and the investigators felt no compelling reason to
insist. In collaboration with the local community leaders,
women’s associations, and neighbouring mothers,
neighbour groups were formed by consensus generally
N
22
18
20
21
8
7
1
5
17
11
13
6
To Mekele
To Maichew
To Addis Ababa
24
23
10
4
3
2
9
12
15
14
16
19
R a y a - a z e b o
A l a m a t a
Control tabias
Key
Intervention tabias
Rural hospital
Health centre
Health station
Regional boundary
District boundary
Tabia boundary
All weather road
Dry weather road
Ethiopia
Amhara
Tigray
Afar
Oroma
Somali
Addis Ababa
Separ
Gambela
Benshangul
Harar
Figure 1: Map of Ethiopia and sketch map of study area
The numbers are the geographical location of the pairs shown in table 1.
SR of
Tabia code
Name of tabias paired
Under-5 mortality
pairs
Number
rate per 1000
1
03 vs 17
Bala vs Maru Hadiskegn
121·2 vs 158·3
2
06 vs 14
Abebagnet vs Haerehiwot
107·5 vs 120·00
3
15 vs 20
Selenwoha vs Hadiskegn (Adiwogenat) 72·2 vs 88·2
4
05 vs 12
Wodefit Abeba vs Harele
61·0 vs 69·4
5
07 vs 19
Bagedelbo vs Genete
58·8 vs 49·2
6
04 vs 11
Adis Berhan vs Mendefera
39·2 vs 40·5
7
09 vs 22
Adis Alem vs Tsega
34·0 vs 38·8
8
16 vs 18
Hadealga vs Boyegerersa
33·8 vs 28·2
9
13 vs 24
Amsalegenet vs Ebohawolt
27·6 vs 14·5
10
02 vs 08
Hadiskegne (Chercher) vs Delate
13·0 vs 13·8
11
01 vs 10
Tao vs Erba Hadiskgne
12·3 vs 11·1
12
21 vs 23
Mechare vs Worabaye
10·8 vs 8·4
Bold tabias were selected from each pair randomly for intervention. When one is
selected for intervention, the other serves as a control. The under-5 mortality rate was
based on the maternal history taken at the time of the census in June, 1996. The
average under-5 mortality in the tabias randomised for intervention was 60·8 per 1000
whereas the rate for the control tabias was 47·6 per 1000.
Table 1: Pairing of the tabias by their under-5 mortality rates
Page 3
For personal use only. Not to be reproduced without permission of The Lancet.
ARTICLES
552
THE LANCET • Vol 356 • August 12, 2000
from contiguous households. Each group selected a
mother coordinator, which resulted in one per 10–22
households in the intervention tabias and one per 15–44
in the control area.
In all tabias a list of children for every mother
coordinator was prepared in a monthly report format.
Mother coordinators were taught to keep track of and
record, in this monthly format, all births and deaths, and
were taught where to refer sick children. The supervisor
could then readily check this report. The supervisors
along with mother coordinators and neighbourhood
mothers verified births and deaths. Supplies of essential
drugs were guaranteed at the health station and tracking
of these drugs was the responsibility of the mother
coordinators.
In each tabia one mother coordinator was chosen to
coordinate all other mother coordinators in the tabia. In
three tabias men were chosen as the tabia coordinator:
one was a CHW, the second was a youth-association
leader, and the third was a CHW and executive for social
affairs of the local community. These coordinators
collected the monthly reports on births, deaths, migration
in and out of the community, and referrals, and checked
whether drugs were short and reported any problems.
Seven field supervisors from the TCBMCP were
appointed to supervise the tabia coordinators through
four to six visits per supervisor each month, and to
directly supervise a sample of the mothers by visiting at
least five of them per day. Opportunities such as market
days were used to meet with the coordinators of the
mothers, often in groups; comments or suggestions were
welcomed.
In the intervention tabias mother coordinators had
additional responsibilities related to malaria. The
TCBMCP provided 20 trainers to train the mothers.
These trainers were taught to train mother coordinators
to teach neighbour-group mothers to recognise
symptoms in their under-5 children that might be a result
of malaria, to give the appropriate course of chloroquine
for their age, to share cloroquine properly, and to
recognise possible adverse reactions from the drug. The
mother coordinators were supplied with chloroquine for
distribution to all households and were responsible for
reporting the use to the tabia coordinator and
replenishing the drugs used. Special pictorial treatment
charts were designed and produced for use and reference
by mother coordinators giving standard chloroquine
doses by age. The only contraindication to giving
chloroquine was if the child had received it within the
past 2 weeks. All presumed malaria cases and doses of
drug given were recorded and reported monthly. The
mother coordinators were also taught to refer a child if no
improvement occurred within 48 h.
Structured verbal autopsies were carried out by our
investigator (GK) on mothers for every third child that
died, which were later reviewed independently and by a
second masked assessor. Deaths were categorised as
either consistent with or possible malaria, or unlikely to
be caused by malaria.
Details of the quality design methods used to assess the
situation that led to mother coordinator approach, the
development of the training cascade, the approach to
selection of mothers and their continued involvement,
the doses of chloroquine given to each child, assessment
of costs and problems that arose, and details of the verbal
autopsies will be published elsewhere.
The training of the mother coordinators in the
intervention tabias took place in November and
December 1996 and mothers began treating children at
the end of December. The field-trial study period was
from Jan 1, to Dec 31, 1997. The census taken in June,
1996, was updated on Jan 1, 1997, and subsequently
each month for the study period, by subtracting all deaths
and those who reached age 5 years during the period. We
12 intervention
tabias with 6383
registered under-5s
13 (19%) definite/
possible malaria
24 tabias with
14000 registered
under-5 paired children
190
(29·8/
1000)
children
died
70 necropsies
done
12 control
tabias with 7294
registered under-5s
366
(50·2/
1000)
children
died
120 necropsies
done
68 (57%) definite/
possible malaria
Figure 2: Trial profile
Pair group
Intervention tabias
Control tabias
Tabia code
Under-5 children (n=6383)
Tabia code
Under-5 children (n=7294)
n
Number who died
Mortality rate
n
Number who died
Mortality rate
(n=190)
(n=366)
1
1
482
10
20·7
10
476
17
35·7
2
5
644
25
38·8
12
577
36
62·4
3
6
513
17
33·1
14
528
32
60·6
4
7
812
21
25·9
19
1027
43
41·9
5
8
449
12
26·7
2
376
25
66·5
6
11
400
11
27·5
4
703
29
41·3
7
13
654
28
42·8
24
731
26
35·6
8
17
361
14
38·8
3
451
24
53·2
9
18
632
10
18·9
16
386
31
80·3
10
20
528
10
18·9
15
627
42
67·0
11
21
491
16
32·6
23
852
41
48·1
12
22
417
16
38·4
9
560
20
35·7
Total
6383
190
29·8
. .
. .
7294
366
50·2
Table 2: Under-5 mortality rate per 1000 child-years according to intervention and control tabias from Jan 1, to Dec 31, 1997
Page 4
For personal use only. Not to be reproduced without permission of The Lancet.
ARTICLES
THE LANCET • Vol 356 • August 12, 2000
553
also adjusted for migration in and out of the community
and new births.
Analysis
The unit of intervention and for randomisation was the
tabia. The sample size of 12 tabias for each group was
determined by the following equation:
15
C=1+(Z
1
+Z
2
)
2
[(r
1
+r
2
)/n+K
2
(r
1
2
+r
2
2
)]/(r
1
-r
2
)
2
Where C is the number of communities (tabias); Z
1
is
=5%; Z
2
is =80%, r
1
and r
2
are the average rates
assumed for the intervention and control groups; n is the
person-time units of observation in each community; and
K=0·25 and is the intrinsic variation between
communities or the coefficient of variation of the
incidence rates.
The minimum expected under-5 mortality for the area
was 55 per 1000 under-5 per year.
16
We used this rate for
r
1
. Estimated malaria specific mortality in under-5s in
hyperendemic to holoendemic areas in Africa
17
is from 20
to 36 per 1000. Other studies in holoendemic areas have
attributed at least a third of under-5 deaths to malaria.
18
Prompt treatment with chloroquine is expected to reduce
mortality from chloroquine-sensitive malaria in under-5s
by at least 66%. For r
2
therefore we used 43 per 1000
(0·055 times one-third=0·0183 malaria-specific times
0·66=0·012 as reduction in rate; 0·055–0·012=0·043).
The study was planned for n to be 570 child-years of
observation in each tabia.
The data were analysed on the basis that all mothers in
the intervention tabias intended to treat their sick
children with antimalarials. Data analysis and
comparison of data were done with a t-test paired and
non-parametric Wilcoxon’s test. SPSS/PC+ (version
7.5), Epiinfo (version 6.046), and Excel software were
used for data processing.
Results
The registered population of the 24 tabias was 70 506,
with 14 001 children less than 5 years of age (figure 2).
Table 2 gives the under-5 mortality rates per 1000
under-5s by tabia and lists them by tabia pair group, one
of which had been randomised to the intervention group
and the other to the control group. The overall under-5
mortality in the intervention tabias was 29·8 per 1000
child-years compared with 50·2 per 1000 in the control
tabias; a 40·6% reduction in the under-5 mortality rate.
The ratio of rates is 29·8/50·2=0·5936. Thus, the
mortality rate reduction is (1–0·5936) or 40·6% [95% CI
29·2–50·6). The difference in rates is 20·4 per 1000
(95% CI from 13·9–26·9 per 1000). The difference is
highly significant; a paired t test gave a test statistic of
3·43 with 11 degrees of freedom (p<0·003). In ten of 12
tabia pairs, mortality was less in those whose mothers
were taught to give chloroquine to their children. Tabia
13, which had the highest under-5 mortality in the
intervention group (42·8 per 1000) was hit by drought,
had a severe dysentery outbreak, and had a measles
outbreak (that also involved 18 other tabias, but not its
paired control, tabia 24). Under-5 mortality in tabia 24
was among the lowest (35·6 per 1000) in the control
tabias.
The differences in mortality between the intervention
and the control tabias held true in each age and sex
grouping (table 3).
There were no important seasonal differences in
mortality between the intervention and control tabias.
The rainfall pattern in 1997 was unusual with rain
occurring in most months; the measles outbreak that
involved 19 of the tabias also may have partly obscured
the expected seasonal increase in malaria deaths in the
control tabias. The measles outbreak continued
throughout most of the year for both the intervention and
control tabias.
The results of the verbal autopsies are given in table 4.
Of the 190 necropsies, only 13 (19%) of 70 in the
intervention tabias were classified as consistent with or
Study group
Possible malaria
Numbers without
Total (%)
(%)
malaria (%)
Intervention tabias
Female
5 (18)
23 (82)
28 (100)
Male
8 (19)
34 (81)
42 (100)
Total
13 (19)
57 (81)
70 (100)
Control tabias
Female
35 (56)
28 (44)
63 (100)
Male
33 (58)
24 (42)
57 (100)
Total
68 (57)
52 (43)
120 (100)
Total
81 (42)
109 (57)
190 (100)
Difference of possible malaria between intervention and control area=38·1% (95% CI:
25·3–50·8);
2
=26·3 (degrees of freedom 1); p<0·001. No difference by sex in the
intervention.
2
=0·016 (1); p=0·579. No difference by sex in the control
2
=0·67 (1);
p=0·471.
Table 4: Cause of death according to verbal autopsy in
under-5s
Age (months)
12
12–35
36–59
Total
Intervention tabias
Male
Number of deaths
61
26
12
99
Under-5 population
632
1189
1476
3297
Mortality rate (per 1000
96·5
21·9
8·1
30·0
child-years)
Female
Number of deaths
38
39
14
91
Under-5 population
563
1145
1378
3086
Mortality rate (per 1000
67·5
34·1
10·2
29·5
child-years)
Total intervention tabias
Number of deaths
99
65
26
190
Under-5 population
1195
2334
2854
6383
Mortality rate (per 1000
82·8
27·8
9·1
29·8
child-years)
Control tabias
Male
Number of deaths
124
44
30
198
Under-5 population
844
1297
1625
3766
Mortality rate (per 1000
146·9
33·9
18·5
52·6
child-years)
Female
Number of deaths
85
56
27
168
Under-5 population
705
1235
1588
3528
Mortality rate (per 1000
120·6
45·3
17·0
47·6
child-years)
Total control tabias
Number of deaths
209
100
57
366
Under-5 population
1549
2532
3213
7294
Mortality rate (per 1000
134·9
39·5
17·7
50·2
child-years)
Total
Number of deaths
308
165
83
556
Under-5 population
2744
4866
6067
13677
Mortality rate (per 1000
112·2
33·9
13·7
40·6
child-years)
Table 3: Under-5 mortality per 1000 child-years in intervention
and control tabias by age and sex
Page 5
For personal use only. Not to be reproduced without permission of The Lancet.
ARTICLES
554
THE LANCET • Vol 356 • August 12, 2000
possible malaria, compared with 68 (57%) of 120 in the
control tabias.
Discussion
The much lower under-5 mortality in the intervention
group shows that although malaria is a major killer in this
population mothers can ably take care of their sick
children when taught and supplied with appropriate
guidance and drugs for home medication. The approach
taken in this study was based on quality design
principles.
19
After analysis of the then current TCBMCP
and extensive discussions with mothers and community
leaders in 1996, it was agreed that the TCBMCP would
train mother coordinators selected in neighbouring
households to recognise possible malaria in their children
and promptly give chloroquine. Although this approach
seems straightforward—and has been considered and
even tried in one form or another
20–22
—the method has
been dismissed because of concerns about the use of
drugs by illiterate, untrained householders. There have
also been concerns about increasing drug resistance from
indiscriminant use, and concerns about logistics and
accountability.
The studies at Saradidi in western Kenya
21
were among
the first to examine community-based malaria control,
but the investigators concluded that there was no
evidence that the programme had any effect on overall
mortality rates or on malaria-specific mortality rates.
However, there were major differences in the nature of
the interventions, in the study designs, and in the study
outcome measures compared with our study. For
example, village health workers rather than mothers were
responsible for providing the antimalarials, no
randomisation of interventions was done, and mortality
outcomes were based on clinical reports of measles,
malaria, or other diseases, but criteria for diagnosis and
source of the reports were not given. There were also no
baseline data for the population in the control area. A
measles epidemic occurred during the preintervention
studies in the two intervention areas; the drop in the
postneonatal, under-5 mortality rate (from 0·0359 to
0·0288) that occurred in these two areas was attributed
to the fall of reported measles cases. The mortality rate of
0·0305 in the control area during this period was judged
to be equivalent to the intervention areas.
The report from Burkino Fasa
22
confirmed that
community-based programmes for training mothers to
make presumptive diagnosis and provide treatment of
their children was both feasible and affordable. However,
the effect on mortality was not assessed.
Studies in the Gambia
23
have shown that antimalarial
prophylaxis given by mothers in the under-5 compared
with antimalarial treatment at nearby primary health care
stations with diagnosis and treatment given by workers
provided a more than 30% reduction in overall under-5
mortality and a 73% reduction in attacks of clinical
malaria. The relative success of the prophylaxis was
attributed to such rapid progression of disease that
children withut prophylaxis died before they could
receive treatment, even though the treatment stations
were nearby. However, despite this substantial reduction,
it was thought that the potential harm that might result
from prophylaxis (potential induction of drug resistance)
outweighed its evident benefit. Consideration also was
given to trying maternal administration of antimalarials
to their sick children,
24
but the efforts under their
circumstances were not effective and the investigators
focused their attention on studies of the promising
insecticide-treated bednet approach.
The limitations of verbal autopsies in diagnosing
malaria are well known,
25
but it was judged that they
could be used to distinguish between deaths consistent
with or possibly due to malaria from those almost
certainly not malaria, such as deaths from measles (well
known locally) or from chronic wasting with protein-
energy malnutrition.
20
The finding that 19% of deaths in
the intervention tabias compared with 57% of those in
the control tabias were from malaria strongly supports
the notion that the differences in under-5 mortality were
due to a reduction in malaria-specific mortality.
Quantitatively, with these proportions, mortality rates
from deaths not consistent with malaria were quite
similar in the control area—22 per 1000 ([1·0–0·57]
times 50·2 per 1000) and the intervention area—24·1 per
1000 ([1·0–0·19] times 29·8 per 1000).
With the reinvigorated global efforts to rollback
malaria, it is vital that increased attention be given to
what family and community-based efforts can achieve
when properly designed and applied in a receptive
setting. With suitable modifications to fit each locale the
approach reported here must be tried in other settings.
However, it is important to recognise the special
biological and sociopolitical factors of the Tigray study
that may limit applicability in other parts of Africa such
as the presence of chloroquine-sensitive falciparum
malaria, a disciplined population accustomed to coping
for themselves, strong community solidarity, and no
alternative income opportunities for the mother
coordinators.
Contributors
G Kidane was responsible for all field work including organisation,
training, data entry, and carrying out of verbal autopsies. G Kidane and
R H Morrow were involved in study design, analysis, and writing of the
paper.
Acknowledgments
We received support from the UNDP/WorldBank/WHO Special
Programme for Research and Training in Tropical Diseases. We thank
the field team workers of Alamata and Mehoni; the Regional Health
Bureau of Tigray; the Department of Malaria Control in Mekele; and
Mesfen Menase and Tedros Adhanom for their support in facilitation
and directives given to get help from their staff at the district levels. We
thank L H Moulton, Department of International Health, Johns Hopkins
School of Public Health for statistical assistance. We acknowledge the
importance of quality design priciples in formulating the mother
coordinator approach to redesigning the community-based primary
health centres as developed through interaction with the USAID
supported Quality Assurance Project.
References
1 Alonso PL, Lindsay SW, Armstrong Schellenberg JR, et al. A malaria
control trial using insecticide-treated bed nets and targeted
chemoprophylaxis in a rural area of The Gambia, west
Africa: the impact of the interventions on mortality and
morbidity from malaria. Trans R Soc Trop Med Hyg 1993; 87
(suppl 2): S37–44.
2 D’Alessandro U, Olaleye B, Langerock P, et al. The Gambian
National Impregnated Bed Net Programme: evaluation of
effectiveness by means of case-control studies. Trans R Soc Trop Med
Hyg 1997; 91: 638–42.
3 Nevill CG, Some ES, Mung’ala VO, et al. Insecticide-treated bednets
reduce mortality and severe morbidity from malaria among children
on the Kenyan coast. Trop Med Int Health 1996; 1: 139–46.
4 Binka FN, Kubaje A, Adjuik M, et al. Impact of permethrin
impregnated bednets on child mortality in Kassena-Nankana district,
Ghana: a randomized controlled trial. Trop Med Int Health 1996; 1:
147–54.
5 Alonso PL, Lindsay SW, Armstrong JR, et al. The effect of
insecticide-treated bednets on mortality of Gambian children. Lancet
1991; 337: 1499–502.
Page 6
For personal use only. Not to be reproduced without permission of The Lancet.
ARTICLES
THE LANCET • Vol 356 • August 12, 2000
555
6 Engers HD, Godal T. Malaria Vaccine Development: current status.
Parasitol Tod 1998; 14: 56–64.
7 WHO Malaria control as part of primary health care: report of a
WHO Study Group (Technical Report Series number 712). Geneva:
WHO, 1984.
8 WHO. Implementation of the global malaria control strategy.
(Technical Report Series number 839). Geneva: WHO, 1993.
9 Mwabu G. Health care decisions at the household level: results of a
rural health survey in Kenya. Soc Sci Med 1986; 22: 315–19.
10 Dabis F, Breman JG, Roisin AJ, Haba F, and the ACSI-CCD Team.
Monitoring selective components of primary health care;
methodology and community assessment of vaccination, diarrhea,
and malaria practices in Conakry, Guinea. Bull World Health Organ
1989; 67: 675–84.
11 Ruebush TK, Kern MK, Campbell CC, Oloo AJ. Self-treatment of
malaria in a rural area of western Kenya. Bull World Health Organ
1995; 73: 229–36.
12 Ghebreyesus TA, Alemyehu T, Bosman A, Witten KH.
Teklehaimanot A. Community participation in malaria control in
Tigray region Ethiopia. Acta Tropica 1996; 61: 45–56.
13 Kloos H. Primary health care in Ethiopia under three political
systems: community participation in a war-torn society. Soc Sci Med
1998; 4/5: 505–22.
14 Barnabas GA, Zwi A. Health policy development in wartime:
establishing the Baito health system in Tigray, Ethiopia. Health Policy
and Planning 1997; 12: 38–49.
15 Smith PG, Morrow RH. Methods for field trials of interventions
against tropical diseases: a ‘Toolbox’ (UNDP/World Bank/WHO
Special Programme for Research and Training in Tropical Diseases).
Oxford: Oxford Medical Publications, 1991.
16 Grant J. The State of the World’s Children. Oxford: UNICEF, 1995.
17 Morrow RH. Epidemiology and control of malaria. In: Nelson KE,
Graham N, Masters C, eds. Infectious disease epidemiology.
Gaithersburg: Aspen Publishers, 2000.
18 Salum FM, Wilkes TJ, Kivumbi K, Curtis CF. Mortality of under-
fives in a rural area of holoendemic malaria transmission. Acta Tropica
1994; 58: 29–34.
19 Plasek P, Systemic design of health care process. Qual Health Care
1997; 6: 40–48.
20 Kaseje DCO, Spencer HC, Sempebwa EKN. Usage of community-
based chloroquine treatment for malaria in Saradidi, Kenya. Ann Trop
Med Parasitol 1987; 81 (suppl 1): S111–15.
21 Spencer HC, Kaseje DCO, Mosely WH, Sempebwa EKN,
Huong AY, Roberts JM. Impact on mortality and fertility of a
community based malaria control programme in Saradidi, Kenya.
Ann Trop Med Parasitol 1987; 81 (suppl 1): S36–45.
22 Pagnoni F, Convelbo N, Tiendrebeog J, Cousens S, Esposito F.