ACCELERATE TO EQUAL: INCREASING THE INVOLVEMENT OF WOMEN AND COMMUNITY IN

VECTOR CONTROL

Mary Hayden, PhD, Research Professor, University of Colorado

Kacey Ernst, PhD, Associate Professor, University of Arizona

Kenya Indonesia

PROJECT OBJECTIVES

• The primary objectives of the project were to:

• Understand the current role and perceptions of women in vector control and

• Identify potential strategies for accelerating the involvement of women in sustained support for vector control interventions at multiple levels and across sectors.

WOMEN C AN BE INTEGRAL MEMBERS OF VECTOR CONTROL STRATEG IES

TIMELINE FOR METHODS

• Nov 2015 - Formative research (FGDs; KIIs), East Sumba Island, Indonesia

• March-April 2016 – Cross-sectional household surveys, East Sumba Island, Indonesia

• June 2016 – Formative research (FGDs; KIIs) western Kenya

• July-August 2016 – Cross-sectional household surveys, western Kenya

• August-November 2016 – Online stakeholder survey

• December 2017 – Stakeholder/Decision-maker workshop, Lake Naivasha, Kenya

• March 2018 - Stakeholder/Decision-maker workshop, Bali, Indonesia

KEY FINDING 1: GENDER NORMS MUST BE ADDRESSED AS PART OF ENGAGEMENT

• Gender norms are associated with women’s willingness to carry out vector control work in Kenya and Indonesia.

Odds ratio: Compare top 25th percentile to rest adjusted for age, education, and parental status

2.4

5.9

3.5

5.55.9

3.12.5

3.5

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

11.0

Fogger Educate Sell Products DeliverProducts

Job in VC Leave beforesunrise

Stayovernight

Travel

ASSOCIATION BETWEEN GENDER NORMS AND WILLINGNESS TO CARRY OUT VECTOR CONTROL ACTIVITIES: KENYAN FEMALES

Odds ratio: Compare top 25th percentile to rest adjusted for age, education, and parental status

11.4

4.6

2.6

6.6

2.31.9

2.5

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

11.0

EmptyWater

Educate SellProducts

DeliverProducts

Job in VC Leavebeforesunrise

Stayovernight

Travel

ASSOCIATION BETWEEN GENDER NORMS AND WILLINGNESS TO CARRY OUT VECTOR CONTROL ACTIVITIES: INDONESIAN

FEMALES

KEY FINDING II : BOTH MEN AND WOMEN SUPPORT WOMEN IN VECTOR CONTROL

• Despite gender norm associations, both men and women equally support women taking part in initiatives in vector control at household and community levels.

KENYA: WILLINGNESS TO CARRY OUT VC ACTIVITIES

97.1

75.8

80.5

81.8

82.5

94.7

80.7

72.5

78.3

81.7

97.3

81.3

81.8

81.5

84.6

97.3

86.4

77.7

77.8

87

0 20 40 60 80 100

Clear the grass and brush around your own compound?

Help a neighbor clear the grass and brush around your …

Assist the community in clearing the grass and brush …

Clean up trash in public spaces?

Help get rid of the places mosquitoes breed in shared…

Empty containers with water?

Educate the community about mosquito diseases?

Sell mosquito control products

Deliver mosquito control products to households?

Take a job to control mosquitoes?

Participants who answered 'yes' to being willing to do the following:

Male Female

*

*

* 𝑥" p − value < 0.05

98.5

63.1

91.9

78.5

70.2

81.0

46.6

28.8

33.2

81.6

98.7

82.2

94.5

81.8

80.1

81.4

63.6

23.7

34.3

76.7

0 10 20 30 40 50 60 70 80 90 100

CLEAR THE GRASS AND BRUSH AROUND YOUR OWN COMPOUND?

HELP A NEIGHBOR CLEAR THE GRASS AND BRUSH AROUND YOUR NEIGHBOR’SCOMPOUND?

ASSIST THE COMMUNITY IN CLEARING THE GRASS AND BRUSH AROUND EVERYONE’S COMPOUND?

CLEAN UP TRASH IN PUBLIC SPACES?

HELP GET RID OF THE PLACES MOSQUITOES BREED IN SHARED AREAS IN THE COMMUNITY ON ROADS BY DIGGING DITCHES AND COVERING STANDING …

EMPTY CONTAINERS WITH WATER?

EDUCATE THE COMMUNITY ABOUT MOSQUITO DISEASES?

SELL MOSQUITO CONTROL PRODUCTS

DELIVER MOSQUITO CONTROL PRODUCTS TO HOUSEHOLDS?

TAKE A JOB TO CONTROL MOSQUITOES?

Participants who answered 'yes' to being willing to do the following:

Male Female

INDONESIA: WILLINGNESS TO CARRY OUT VC ACTIVITIES

* 𝑥": statistically significant

KEY FINDING 1II: NEW STRATEGIES ARE NEEDED

• Current strategies to engage more women are not perceived as effective.

0% 10% 20% 30% 40% 50% 60% 70%

Training existing community health workers

Recruiting from secondary schools

Talking to community leaders

Recruiting from media sources

Job opportunities distributed through schools

Talking to opinion leaders

Talking to women's groups for recruitment purposes

Providing funding for micro-enterprises

Ensuring job security during pregnancy

Protective equipment specifically designed for women

Making structural changes to facilities

STRATEGIES CONSIDERED EFFECTIVE & HISTORY OF IMPLEMENTATION

Percieved as effective Has already been implementedPerceived as effective Hayden et. al. AJTMH 2018

KEY FINDING IV: STRATEGIES MUST BE TAILORED TO THE COMMUNITY

• No one-size, fits all – strategies to focus on the way forward need to be contextualized by setting

• Engaging women has be part of a broader process for bringing in new interventions to a community

• Different strategies will be preferred and supported in communities

• Community buy-in which includes women will increase the effectiveness of the interventions and improve long-term sustainability

Advocate for more women in decision-making through access to information• Conduct a needs

assessment on existing knowledge gaps

• Develop curriculum geared towards information access at the household level

Develop sensitization and advocacy materials

• Promote job ads• School-based

curriculum• Community theater

programs• Use social and

mainstream media platforms to disseminate messaging

Identify key community influencers and champions of women in vector control• Sensitization workshops

with key employers • Commitment by govt.

officials and private industry to enact gender equity policies

• Identify female leaders who can act as mentors and role models

Prioritize women’s employment in vector control• Review and identify gaps

in gender equity• Develop female-

centered training opportunities

• Require reporting of ratio of men and women who are employed in VC programs to funders

STRATEGIES TO NORMALIZE WOMEN’S ROLES IN VECTOR CONTROL

Ernst et al. Malaria Journal 2018

KEY FINDING V: ENGAGING WOMEN IN VC MAY HAVE BROADER BENEFITS

• Barriers and opportunities for engaging women in vector control should be addressed to promote the effectiveness and sustainability of vector control programs

• Empowering women to work in vector control may provide a neutral entry point leading to increased agency for women in other sectors

• Wide-ranging health impacts

Ernst et al. Malaria Journal 2018

NEXT STEPS: IMPLEMENT PILOT PROJECT

Overall objective: To develop a community-led vector control strategy which engages women as leaders but not to the exclusion of men

Five primary components: ­ Conduct asset mapping to identify community resources (e.g. women’s groups, NGOs, and key leaders)­ Design a rapid assessment protocol to identify and address gaps in knowledge VBD and prevention in

community­ Initiate community working group that engages women (and men) from different sectors: community, health,

leadership, schools, religious organizations­ Develop workshop protocol to create a strategic plan for community implementation of vector control; ­ Standardize procedures for introduction of new interventions

Standardize tools for implementation based on disease

system

Develop protocol for strategic planning

Initiate working group with specified

proportion of women

Identify gaps in knowledge

Conduct asset mapping

CREATE A SYSTEMATIC PROCESS TO ENGAGE WOMEN AND THE BROADER COMMUNITY IN

VECTOR CONTROL

• Objective: Implement and evaluate a standardized community-engagement process for targeting women (and other community members) as agents of change through vector control.

• Hypothesis 1: Implementation of a systematic process to engage women in the community in vector control will result in higher acceptability of the proposed intervention(s).

• Hypothesis 2: Indirect benefits of the engagement of women in vector control activities will be an increase in reported agency.

DEVELOP STANDARDIZED TOOLS TO PROVIDE ACCEPTABLE AND SUSTAINABLE

INTERVENTIONS

• 1. Assess: Conduct asset mapping to identify existing women’s groups, NGOs, and key influencers in the community. Carry out baseline assessment of women’s agency.

• 2. Prepare: Hold community-engaged workshops to prioritize and organize community-led strategies for vector control

• 3: Train: Educate and train community women as vector-control implementers

• 4: Notify and Nudge: Initiate a seasonal alert process at the beginning of the transmission season based on our simple model. Implement a checklist of activities to determine whether the family is prepared for the transmission season. Work with families to design strategies that will motivate them to continue with interventions.

EVALUATE PROCESS

• 5: Cost: Identify the economic benefits of the intervention to women and the community.

• 6: Evaluate: Evaluate adoption of intervention(s), sustainability of intervention(s) and change in agency among women involved in vector control.

• 7. Evaluate: Undertake long-term evaluation of reduction in vector abundance and improved disease outcomes.

ACKNOWLEDGEMENTS

• Maseno University; Maseno, Kenya

• Maurice Agawo

• Eunice Toko

• Guyah Bernard

• Wirawacana University; East Sumba, Indonesia

• Norlina Kalunga

• Linda Rambu

• Maklong Killa

• RambuYetti Kalaway

• Umbu Ho Ara

• Salmon Pandarangga

• Funding provided by Bill and Melinda Gates Foundation

• University of Arizona; Tucson, AZ

• Jayleen Gunn

• Karla Rascon-Garcia

• Erika Barrett

• Katherine Center

• Mandy Kendall

• Megan Huyhn

• National Center for Atmospheric Research; Boulder, CO

• Andrew Monaghan

• Deborah Brunson

• The Indonesia and Kenya working groups

THANK YOU!

• mhayden@uccs.edu

• kernst@email.arizona.edu

OVERVIEW OF METHODS

• Field Project sites• East Sumba Island, Indonesia

• western Kenya

• Mixed methods research• Online stakeholder survey (n = 93, RR =

38%)

• Focus group discussions (n = 16) and key informant interviews (n = 27)

• Cross-sectional household surveys (Kenya (M) n = 349, (F) n = 548; Indonesia (M) n =236, (F) n =521)

• Decision-maker workshops in Indonesia and Kenya

CURRENT ENGAGEMENT PROCESSES

• Currently, there are 2 primary approaches:

• User-centered design:

• An iterative design process in which designers focus on the users and their needs in each phase of the design process.

• may not be generalizable

• costly

• Scientific evidence given less weight than consumer needs

• Consumer model has different end purposes

• Top-down

• Product is selected for implementation in the community

• Leaders are engaged to get “buy-in” from community members and leaders

• Harder to tailor to community needs

• Less decision-making in process may mean lower acceptance/ sustainability

HOUSEHOLD SURVEY METHODS

­ Sampling­ Stratified by­ Urban/ Rural­ Level of malaria transmission

­ Generated random points for cluster sampling proportional to population size

­ Inclusion criteria­ Women over 18­ Resident for at least 6 months­ Living with partner

­ Survey­ Informed by KII and FGD­ 50 item survey­ Paired male and female if available­ Gender-matched interviewers­ 9-item gender norms metric

Example point generation map for Kenya

Household

Community

Employment

• Clear grass and brush around owncompound

• Empty containers of water

• Help a neighbor clear the grass and brush• Clear the grass and brush around everyone’s

compound • Clean up trash in public spaces • Dig ditches and cover standing water • Empty containers with water • Educate the community about mosquito

diseases

• Sell mosquito control products• Deliver mosquito control products to

households • Take a job to control mosquitoes • Leave before the sunrises • Sleep overnight for trainings • Travel to other villages on regular basis

GENDER NORM SCORE METHODS

Question Yes NoA woman has the skills or the natural ability to start and run a business on her own +1 -1It is more important for boys to graduate secondary school than girls. -1 +1Women should take part in politics. +1 -1Sons are the only thing a woman can rely on in her old age. -1 +1It is acceptable for a woman to question her husband’s opinions. +1 -1A woman must talk to her husband about expenditures. -1 +1A woman should have her own money to use as she decides. +1 -1A husband should let his wife work outside the home if she would like to. +1 -1If it is a question of children’s health, it is best to do whatever the father wants. -1 +1

• Gender norm score calculated based on answers to 9 questions (See below) • Range: -9,9• Categories: -9-0; 1-3; 4-6; >6