Combining malaria control with rural electrification : social and behavioural factors that influenced the design, use and sustainability of solar-powered mosquito trapping systems (SMoTS) for malaria elimination on Rusinga Island, western Kenya

Chapter 1 presents the background information relevant to the subject matter and methods of this thesis. These include the application of social and behavioural sciences in malaria control, the SolarMal project and malaria in Kenya. It also presents the research objective, question and design that informed this thesis. Chapter 2 systematically documented and analysed how the mosquito trapping technology and related social contexts mutually shaped each other and how this mutual shaping impacted the design and re-design of the intervention. Our analysis focused on the design, re-design and piloting of the innovative approach to controlling malaria largely before its field implementation had started. During the pre-intervention year, various aspects of the intervention were re-designed ahead of the project roll-out. Changes to the technology design included removal of carbon dioxide from the blend, trap improvements and re- design of the electricity provision system. In order to gain and maintain the support of the community and organisations on the island, the project adapted its implementation strategies regarding who should represent the community in the project organisation team, who should receive solar-powered mosquito trapping systems (SMoTS), and in which order the systems should be rolled out. This process involved not only the project team and the producers of the different components of SMoTS, but also included feedback from the residents of Rusinga Island. This process of incorporating feedback from a broad range of stakeholders utilized data from the entomological, technical and socio-behavioural researches as well as data from more broad engagements with the social environment of the study population and setting. The analysis demonstrates how system innovation theory helps to provide insights into how a promising malaria control intervention evolves and matures through an interaction between technical and social phenomena. This part of the study demonstrated that SolarMal was not only a technical innovation, but similar to other malaria strategies, required new social organisational arrangements to go with it. In chapter 3, this thesis investigated immediate community response to the innovation and the implications for ongoing implementation and supportive community communication outreach. The explorations found that the main benefit of SMoTS to study participants was house lighting and suggested that the main reason that people adhered to recommended behaviours for SMoTS deployment was to ensure uninterrupted lighting at night, rather than reducing mosquito biting or malaria risk. Electrification led to a number of immediate benefits including reduced expenditure on kerosene and telephone charging and conveniences (such as lit early mornings and late nights, increased study hours, etc.). The changes brought about by electric lighting provided conveniences which improved the welfare of residents. Some respondents also reported hearing fewer mosquito sounds when interviewed a few weeks after a SMoTS was installed in their house. On the question of maintenance, we found that residents of Rusinga Island adequately maintained SMoTS. Households also reported maintenance needs to the project and project technicians carried out repair and maintenance needs. Chapter 4 documented the perceived impact of SMoTs on family dynamics, social and economic status, and the community as a whole. The findings suggest that even when the use of energy is restricted, electricity can enhance the value of life. Although data on malaria prevention was yet to be fully collected and analysed, there was evidence of enhanced socio-economic and emotional well-being of study participants which may enhance the desire to sustain the intervention. In the end, this may be a double-edged intervention that delivers health benefits and contributes to improved welfare. The utility, social significance and emotional benefits experienced with the lighting component of SMoTS may create the desire to sustain the intervention. However, the motivation to sustain the whole SMoTS will also depend on the results of the entomological and parasitological components of this intervention. Chapter 5 evaluated the knowledge, perceptions and practices related to malaria control before and after the roll-out of solar-powered mosquito trapping systems. As a malaria control strategy, SMoTS were installed in Rusinga to complement the existing use of long- lasting insecticidal nets (LLINS) and prompt malaria care seeking. The message about the complementariness of SMoTS as a malaria strategy was further stressed during social mobilisation to encourage continued use of LLINs and prompt malaria care seeking. The findings suggest that overall, the SolarMal project did not induce a negative effect of the innovation on the uptake of existing malaria strategies. The continuation of LLIN use and recommended malaria treatment seeking was likely contributed to by the social mobilisation component of the SolarMal intervention as well as a mass distribution of LLINs campaign, suggesting the need for a strong continuous demand generation exercise. The number of respondents who reported that mosquito densities had reduced was much higher at the end of the research phase confirming that the recorded entomological changes (that showed SMoTS had proved effective in controlling mosquitoes) had also been experienced by residents. Chapter 6 investigated whether the community preferred individual or cooperative solutions for organising the sustainability components of SMoTS, and whether and how known social dilemma factors could be recognised in the reasoning of actors. The findings of the explorations of sustainability of installed SMoTS beyond the research period did not portray a promising picture. While residents were unanimous that they would like to continue enjoying the benefits of SMoTS (especially house electrification), it appeared that residents preferred largely individual approaches. Yet the individual approaches suggested by residents for sustaining SMoTS may be realistic for sustaining only the lighting component. Sustaining the mosquito control component, which is what would impact malaria, requires more resources (than the lighting component) and may be better facilitated by more collective undertakings by residents. Residents expressed concerns about working collectively with others that seemed to suggest that the situation had features of a social dilemma. Chapter 7 synthesises the main findings. Subsequently, this results in the overall conclusions of the thesis that are discussed within the broader debates on research and policy. This thesis shows that SolarMal was not only a technical innovation, but required new social organisational arrangements to go with it. The intervention was a composite of which the technical component was one and focussing on it without the others may have negative implications for effectiveness. By implication, the scaling up of SMoTS will also require scaling-up the intervention process and social organisation that played a role in its effectiveness in the trial setting. This thesis also demonstrates the importance of flexibility and continuous learning in multiple spheres in a complex multidisciplinary innovative intervention to control malaria. The key addition to the knowledge base for similar public health programs is that intervention design is not a one-off occurrence and neither is implementation a linear process. Social science research was a core component in this process and the process required not only integrating social inquiry into the design, but also into planning, implementation, and monitoring. This contributed to ensuring that flexibility and adaptability to the local realities were built into the SolarMal intervention and contributed to the success of the intervention. Rather than project management, persons involved in rolling-out innovations should perhaps focus on adaptive and proactive management and on facilitating change. While managing emphasises control and certainty, an innovation process requires flexibility to allow continuous adaptations which characterise the process. In practice, this means keeping attuned to perceiving signals, analysing feedback loops and using those signals to mitigate what is not going well or amplify what is going well.